Are They Calling Your Herniated Disc a Lumbar Strain?

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There is a renewed trend among particular self-insured employers and third-party administrators (TPA's) in Nevada to send a Notice of Claim Acceptance for "lumbar strain only" on low back injury claims. My fellow claimants' attorneys are also noticing an increase in claims where adjusters are denying medical treatment for a herniated disc, because the claim was accepted for a "lumbar strain" and the injured worker didn't file a timely appeal.

For those workers who truly have a lumbar strain, a claims acceptance letter for a "lumbar strain" isn't likely to be a problem. However, the the claims acceptance letter must be sent by the adjuster 30 days after getting the C-4 Claim for Compensation from the first doctor. It isn't likely that the injured worker or even the adjuster will know whether a low back injury is a strain or something else at that time.

It's rare for a work comp adjuster to authorize a MRI during the first 30 days of the claim, or even within the 70-day time to appeal the limiting language in acceptance letter. A MRI is necessary to diagnose a disc injury. If a herniated disc is diagnosed later, the adjuster may refuse to authorize any treatment that isn't treatment for a lumbar strain.

According to local neurosurgeon Aury Nagy, M.D., 70% of patients with lower back pain get better with physical therapy and steroids in about 6 weeks. When the patient isn't better, an MRI is done. The MRI must be authorized by the adjuster. If the MRI shows a herniated disc, where the gel-like material within the disc is bulging or has ruptured and is pressing on a nerve, then a surgery may be necessary. The patient may need a discectomy to remove the damaged disc. If the spine is also unstable, a fusion may also be necessary.

Physicians must ask the adjuster for authorization to do injections or to surgically treat a herniated disc. Some adjusters are now including the "lumbar strain " language of almost every claim acceptance letter for low back injury. Obviously, it isn't fair to the injured worker for the adjuster to deny requested treatment for a herniated disc that isn't diagnosed until later in the claims process. The fact that adjusters are using this unfair tactic frequently now tells me that it is working for the adjusters. Surprisingly few injured workers get legal help when this happens.

These are often winnable cases when the claimant files an appeal after hiring an attorney, even after the time has passed to appeal the "lumbar strain only" acceptance letter. If your orthopedic surgeon or your treating neurosurgeon tells you that the adjuster denied authorization to treat your herniated disc because only a lumbar strain was accepted on your claim, get an attorney consultation immediately to discuss the facts of your particular case.

 

Topics:  Denial of Benefits, Herniated Disc, Insurers, TPAs

Published In: Labor & Employment Updates, Worker’s Compensation Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Virginia L. Hunt, Law Office of Virginia Hunt | Attorney Advertising

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