Before paying for knee surgery, there are several things your employer’s insurance company will take into consideration.
Imagine you were involved in a workplace accident and suffered an injury that requires knee replacement surgery. Will the workers’ comp cover your surgery? Fortunately, Missouri’s workers’ comp generally covers most necessary medical procedures, including surgery.
However, before paying for your knee surgery, your employer’s insurance company will typically conduct a utilization review (UR) to determine whether the knee surgery is medically valid. Here are key factors the insurer will look at when approving knee replacement surgery.
What’s the age of the injured worker? Workers’ compensation insurance companies are more likely to throw out a knee injury claim made by older people. Older adults are susceptible to underlying conditions like arthritis and wear and tear, which they may claim damaged the knee before the accident.
2. Evidence of Previous Knee Treatment
The insurer will generally demand medical records. Previous knee treatment proves that the knee had an underlying medical issue before the accident. If you had been treated before, you must have the MRIs and X-rays, which the insurer will compare with the recent ones when looking for significant changes of a degenerative or accident-related nature.
3. Inability to Perform Work Duties
Did the worker have a very physical or menial job for several years before the accident occurred? If so, can the worker still undertake the same duties efficiently? If the answer is yes and you can no longer work the same job, getting surgery approval is much easier.
4. Details of the Accident
The insurer will look at your record of how the work-related accident occurred. Accidents that cause much trauma to the knee have better chances of approval for total knee replacement surgery.
Insurance companies often try to blame accidents and resulting injuries on the victims to avoid paying compensation. For example, the insurer may recommend a utilization review from their preferred medical specialist, hoping that the physician will conclude that the medical procedure is unnecessary. They may also arm-twist the medical specialist into saying that while the knee surgery is necessary, it was influenced by arthritis or other conditions and not the workplace accident.
An experienced St. Louis workers’ compensation attorney can help connect you with an Independent Medical Evaluation specialist. An Independent Medical Evaluation specialist can provide enough medical evidence to support your claim and prove that your injuries were caused or aggravated by your workplace accident.
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It generally isn’t advisable to pursue a workplace injury claim on your own. The process is often long, complex, and stressful, especially without a legal background. What’s more, facing cunning insurance adjusters alone will only increase the likelihood of making mistakes that could be used against you. Give us a call 24/7 to speak with a workers’ compensation attorney with over 25 years of experience.
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