Shoulder Injury Surgery denied

[4104ever]

First of all, my injury happened in the state of Florida. On 3/31/11 I fell in the parking lot of a location my employer had sent me to. I tripped over a parking curb and fell very hard on my right side. I experienced instant excruiating pain to my right shoulder. To try and keep this as brief as possible I was eventually sent for an MRI which showed:

1. full thickness tears of the supraspinayus and infraspinatus tendons with severe retraction of the tendon and early atrophy of the muscle fibers seen as edema within the muscle fibers..The infraspinatus tears are seen running into the muscle fibers.
2. high grade partial tears of the subscapularis tendon running into the muscle fibers. No atrophy of the muscle is seen.
3. Moderate to severe fluid collections are seen within the subacromial/subdeltoid bursae
4. Complex tears of the superior, posterior and inferior glenoid labrum are seen.

There is more but these are the highlights Ortho Dr says the subscapularis tear is a new tear and possibly the labrum tears, but everything else is a pre existing condition and because of this IC will not approve surgery even though I absolutly need it ASAP.

I have been in physiacal therapy 3x weekly just to keep the shoulder from freezing.

The IC Dr (ortho) did tell me today that he would testify for me that my work of the last 14 years most likely caused these pre exisiting conditions. I was a mobile photographer and lifted and carried my studio in and out of locations plus the repetitive motions of raising backgrounds and lights up and down.

I have very limited range of motion now..can't raise my arm to even brush my hair. Before the fall I wasn't even aware of having any disability. (rotator cuff damage). I did my job fully and well with never a complaint of any pain or limited motion.

I was released to light duty work with a 5lb lifting restriction starting May 19. What they have me doing is horrible. I show up but basically do nothing. Very depressing.

By the way I am a 62 year old female and I realize that my career is finished. Dr says even with surgery he would expect only a minimal recovery. I do have an attorney and he has filed a petition for authorization of surgery and psychological treatment. Needless to say I am in alot of pain and emotional stress is taking it's toll. Also, my blood pressure which has been regulated with medication for years is very high now.

I guess my question now would be, has anyone here had similar problems with pre existing conditions and what hope do I have that I may get my required surgery?

Thank you all ahead of time for any help you may give me.

[jayne]

ouch I know the shoulder injuries are painful...Kate is the Fla.pro she will be along soon good luck

[1171]

the ortho needs to put their supporting medical opinion into a report for you.
then you need to appeal the denial by contacting the Employee Assistance Office for help in completing a Petition for Benefits.
For assistance call: (800) 342-1741 or e-mail wceao@myfloridacfo.com . For the location of the nearest EAO, click on: http://www.myfloridacfo.com/WC/dist_offices.html .

for more information

http://www.myfloridacfo.com/WC/info.html

as the appeal process takes awhile you might want to get your necessary treatment thru your health plan. they will need written copy of the comp denial.

[4104ever]

(06-30-2011 12:32 AM)1171 Wrote:  the ortho needs to put their supporting medical opinion into a report for you.
then you need to appeal the denial by contacting the Employee Assistance Office for help in completing a Petition for Benefits.
For assistance call: (800) 342-1741 or e-mail wceao@myfloridacfo.com . For the location of the nearest EAO, click on: http://www.myfloridacfo.com/WC/dist_offices.html .

for more information

http://www.myfloridacfo.com/WC/info.html

as the appeal process takes awhile you might want to get your necessary treatment thru your health plan. they will need written copy of the comp denial.

My attorney filed the petition Monday. I am under the assumption that as long as I am on worker's comp my private insurance won't touch a work related injury.

[NewDriver]

4104Ever, to a degree you are correct in that your PHC/Private Health Care, will not touch a work injury. However, as 1171 has pointed out, at the moment your WC has denied you the treatment you so desperately need. I too had a nasty Rotator Cuff injury back in 2007 and waited over 7 months for WC to approve my surgery. I did a pile of PT to attempt to keep from getting the frozen shoulder and in the end I still need up with a partial frozen shoulder even AFTER the surgery.

As to your PHC so long as you show them the denial from WC they can and should pay for your surgery NOW and file a lien against the WC IC for reimbursement AFTER your attorney gets the WC IC in front of a judge. That could take a while and in the mean time you are at high risk of complete frozen shoulder and with the other injuries you have you do NOT want that as well.

Also in WC there is NO legal basis for denying a claim based on pre-existing for medical care. They take you on in "as is" condition and that is just simply the law. They certainly can and will drag this out as long as they can. But, I can assure you that in the end when a judge tells them YES they will pay for the surgery, (which IF you elect to go ahead and have it done NOW would amount to a reimbursement to your PHC and to you for any out of pocket expenses in relation to the surgery).

Having been down the road with both my rotator cuffs being surgically repaired I strongly suggest that you consider having the surgery now and let the legalities be worked out as it could take a very long time to get this to a comp court.

Best of luck to you.

[kate]

If a new injury aggravates a pre-existing condition it is usually compensable. That doesn't mean the IC won't try to deny it. But they will lose in the long run if the medical evidence supports it.