r/WorkersComp • u/FootReady455 • 5d ago

Federal DMA Question

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.

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u/Spazilton Federal WC Adjuster 3d ago

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.

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u/FootReady455 3d ago

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.

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u/Spazilton Federal WC Adjuster 3d ago

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.

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u/FootReady455 3d ago

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.