One indisputable fact about medical care is that unless it’s an emergency situation, you will start with more conservative medical care before getting more expensive medical care. The simplest example would be if you hurt your shoulder. Before surgery would get approved, you’d be asked to rehabilitate yourself through physical therapy. If that fails then it’s likely that a surgery would be a reasonable next step.
Another indisputable fact is that the more rare or expensive a medical procedure is, the more likely you are to face resistance from the work comp insurance company. But don’t give up hope.
This was the case of a first-grade teacher in Bloomingdale who had a fall in her classroom which resulted in a terrible break to her elbow and eventually surgery. Her recovery wasn’t great and she had to have two more surgeries. Luckily for her, those procedures were approved and paid for.
As time went on she had continuing pain in her elbow and was eventually diagnosed with complex regional pain syndrome, also known as CRPS or RSD. She had a lot more treatment including medication, epidural injections, and even a spinal cord stimulator. None of that solved her problem, unfortunately.
CRPS can go from one body part to another. It’s really vicious. As that’s what happened to this teacher, her doctor recommended replacing the spinal cord stimulator with a DRG or Dorsal Root Ganglion Stimulation device. It’s used to deal with chronic pain.
The doctor testified it was the newest product in the field of spinal stimulation. Because it’s new, that made it rare, and as a result, the insurance company denied approval for it. Under Illinois law, medical payments must be approved if they are reasonable. Insurance companies have won cases in the past by arguing that proposed treatment is either experimental or not medically acceptable.
A DRG works by placing electrodes along the nerve root instead of on the spinal cord itself. Her treating doctor testified that this procedure had better results in reducing pain in CRPS patients. Because her pain had gotten worse and not stabilized, the Arbitrator found that it was reasonable for her to replace the spinal cord stimulator with this newer device that appears to be better suited for treating the problems that she has. It was apparently persuasive to the Arbitrator that the treating doctor felt that this device gave her the best chance of returning to work as it could relieve a significant portion of her symptoms.
The big takeaway is that while something like healing crystals will never get approved, if you’ve tried other things without success and your doctor is credible, getting newer procedures approved isn’t impossible and might even be likely.
These are rarer but tougher cases that certainly require a lawyer. Nothing is more important than your health and you don’t want to miss out on needed treatment. If you’d like a free, confidential consultation with an attorney, please contact us any time.
Bonus tip. When injuries are this serious, we see a lot of insurance companies trying to get you to settle your case before you are healthy. Never do this. Once your case is settled you typically lose your rights to medical care paid for by them and would also lose your weekly benefits. The settlement money will be there when you are ready. Don’t let them frustrate you into doing something that isn’t in your best interests.