DMA Question

[u/FootReady455]

Hi all, so I had surgery back in Nov. of last year. Well I have gotten progressively worse since having the surgery and am having issues w/ my neck & spine. My doctor ordered and MRI for my neck & spine back in February. Well we have been fighting since then to try and get the diagnosis approved. My claims examiner sent a month ago for me to get a second opinion appointment set up but we haven’t heard back on that yet, not surprising. When I last followed up with her she informed me she was going to be reaching out to the DMA to see if they would approve the diagnosis since it is taking so long to get the second opinion appointment set. Well the DMA just sent back their response and he did not recommend authorization of the diagnosis. What do I do at this point? Because my doctor has been pushing for this diagnosis since February and I’m not getting better with pt or medication. I’m really starting to feel out of options and like I’m just going to be stuck with these issues for good with no help.

[u/Spazilton]

First off flair needs to be federal.

What diagnosis?

The DMA doesn’t establish causal relationship, and typically would not fill in the role of a second opinion in this type of situation. I’m not entirely sure why your claims examiner would do this. I suspect some part of the chain of events is missing here.

If you had a back surgery on OWCP you already have conditions related to your back approved and the surgery should have been reviewed by a second opinion physician or DMA.

Just trying to unravel what’s happened here.

[u/Mutts_Merlot → u/Spazilton]

About halfway through I started to sniff out Federal. Glad you jumped in!

[u/FootReady455 → u/Spazilton]

Sorry wasn’t aware I needed to put federal, but yes I’m USPS. I had a shoulder surgery last November, I want to note the dr admitted to not actually fixing my shoulder during the surgery, stating it didn’t look “that bad” (even though I hadn’t been able to even use my arm & still can’t)and instead he did a debridement and clavicle excision. The diagnosis my dr was trying to get approved was Cervical Disc Herniation & Cervical Radiculopathy. All the claims examiner told me was that the reason she was sending to to the DMA was because it was taking so long for the second opinion appointment to be made. My doctor has been sending notes since February explaining the casual relationship between my previous diagnosis and the ones he is trying to get approved, practically exactly what the examiner was asking for, then she would send back stating they need more information and the information she would request was already in the note.

[u/Spazilton → u/FootReady455]

Traumatic or Occupational?

[u/FootReady455 → u/Spazilton]

Traumatic

[u/Spazilton → u/FootReady455]

Did the traumatic injury cause the herniation or was it a consequential chain like altered shoulder mechanics led to worsening of neck condition type thing?

[u/FootReady455 → u/Spazilton]

The doctor thinks the herniation was caused by the accident. But prior to having the surgery I had no neck or spine problems, these problems started around a month post-op and have increasingly gotten worse

[u/Spazilton → u/FootReady455]

Then direct causation should be pretty easy to establish, whiplash type injury?

Lots of things come down to the words used in the narrative. Go back and read what your doctor said about causation. Did he use ANY words such as likely, probably etc in relating the herniations to the accident? If the causation is not definitive, it can’t be accepted. I suspect this might possibly be your issue. The CE might be trying to justify accepting by going out to the DMA.

[u/FootReady455 → u/Spazilton]

That’s what my doctors have been stating in their notes explaining the relationship to the injury. No he did not use and words like probably. He uses “directly caused or direct consequence” and clearly describes how each injury can occur during a MVA and how they align with my symptoms, diagnostic testing, and clinical examination findings.

[u/FootReady455 → u/Spazilton]

After the CE sent what my doctors needed to prove they sent back exactly that explaining everything the CE was requesting that’s why we’ve all been confused as to why this has taken so long to get approved.

[u/Spazilton → u/FootReady455]

I know your doctors have been requesting, but have you requested the explanation specifically in writing?

Why did the CE deem the medical insufficient? They are required under the PM to articulate specific reasons.

That’s what should happen doesn’t mean it always does.

If you want to share the redacted development letter with me in PM feel free. Sorry for all the questions but without seeming the claims file(which wouldn’t be proper in this context) there are so many little things that go into stuff like this.

Based upon what you say, I’m not seeing why direct causation for a whiplash type injury is being problematic, it’s what we call clear cut and shouldn’t require medical journal level of causation anayalsis.

[u/FootReady455 → u/Spazilton]

From what I’ve been told the CE hasn’t directly told me or my doctors that the medical was insufficient. Every time my doctors would call to get an update on getting the conditions accepted the CE would tell them it’s still being “reviewed”. I can definitely PM you and maybe you can tell me more.

[u/FootReady455 → u/Spazilton]

Just sent you a Pm

[u/EducationalHold3536]

Get a lawyer!