Workers Comp Denied MRI: How to Get Insurance Approval

What to Do When Workers Compensation Won’t Pay for Magnetic Resonance Imaging (MRI)

Following These Steps Can Help You Obtain Insurance Approval for a Prescribed MRI for Your Work Injury So That You Can Get It Scheduled

Medical imaging helps your doctor diagnose the nature and extent of your occupational injury, prescribe a treatment plan, and monitor the success of physical therapy or surgery.

Of the diagnostic imaging available, Magnetic Resonance Imaging (MRI) is the most crucial test in many work accident cases. Indeed, one treatise says that MRI is the gold standard for diagnosing some of the most common work injuries.

We agree that MRI is critical to evaluating claims involving orthopedic injuries to the spine, joints, bones, ligaments, and tendons (but less valuable in many work-related head injury and concussion cases).

Your MRI results often determine and answer whether –

• You receive only conservative treatment or whether you are a surgical candidate.

• What medical specialists will provide care for your specific injury?

• How soon will your doctor declare that you have reached maximum medical improvement (MMI) and refer you for a functional capacity evaluation (FCE) to determine permanent restrictions?

This information affects workers compensation settlement value.

Despite this importance, workers comp insurers frequently deny MRI authorization and approval. Indeed, our personal injury law firm receives several phone calls from injured workers each month because of claims adjusters who have denied MRI authorizations with insurance carriers and claim administrators (Sedgwick, ESIS, etc.).

This article explains what you must prove to get an MRI approved by workers compensation. With the proper evidence, you can get Magnetic Resonance Imaging covered by the insurance company so you can decide on the next steps for your work-related injury claim (for example, keeping the lifetime medical award versus settlement). 

Read on for more information. 

Then call us at (804) 251-1620 or (757) 810-5614 if you have any questions about workers compensation. See why thousands of auto accident victims and injured employees have asked us for help.

Types of Magnetic Resonance Imaging

MRI tests come in different forms. 

Common examples of Magnetic Resonance Imaging tests include the following:

• Functional MRI (fMRI): This test assesses brain activity while you do specific tasks. Researchers interested in brain mapping usually use fMRI.

• Cardiac MRI: This test produces images of the heart and surrounding structures. Your cardiologist may order this MRI if you are a first responder (police, firefighter, emergency medical technician) with a lung or heart disease claim.

• Diffusion (diffusion-weighted MRI): This MRI test can detect early cerebrovascular accidents (CVAs), strokes, and brain white matter disease. It can also be helpful in traumatic brain injury (TBI) lawsuits.

Who Orders the MRI?

Your treating physicians will order all diagnostic procedures, including Magnetic Resonance Imaging.

In workers compensation, the orthopedic doctor or neurosurgeon usually orders the MRI when conservative treatment (PT, chiropractic care, acupuncture) has failed to heal you or reduce your symptoms to a manageable level.

What are Common Occupational Injuries Requiring MRI?

We often see doctors order workers compensation MRIs in these situations:

• A low back injury (lumbar strain) or pinched nerve in the neck fails to heal with conservative treatment, so your doctor orders the imaging to see if you have a herniated disc, spinal stenosis, or some other degenerative condition.

• Your doctor orders a knee MRI to see if you suffered a torn anterior cruciate ligament (ACL) or meniscus because your leg continues to give out after you slipped at work and fell.

• You struck your shoulder in a forklift accident, so your doctor orders a shoulder MRI to check for a torn rotator cuff.

• You suffer a crush injury to the hip and pelvis when an unstable load falls from a crane and hits you, so your doctor orders Magnetic Resonance Imaging of the pelvis.

Is an MRI Better than a CT Scan?

Your doctors may prescribe MRI and CT scans when treating your work injury. 

The primary advantages of Magnetic Resonance Imaging over CT scan are that:

• MRI provides more detailed images of the soft tissues, which makes it helpful in evaluating symptoms coming from the brain, spinal cord, abdomen, eye, ear, knee, ankle, foot, hand, shoulder, or heart. Indeed, MRI is better at showing degenerative disc disease (DJD), degenerative joint disease (DJD), or osteoarthritis.

• Magnetic Resonance Imaging gives a better contrast between normal tissues and abnormal tissues.

• MRI can produce cross-sectional images in any direction throughout your body. This increases the likelihood that your doctors can pinpoint the cause of your pain, numbness, tingling, weakness, or headaches.

However, Magnetic Resonance Imaging does have some drawbacks. For example:

• It requires a high level of cooperation because, depending on the purpose of the imaging and the availability of an open MRI scanner, you must stay still for a significant period. This test is challenging, if not impossible, for injured workers with claustrophobia or anxiety.

• Those with implanted medical devices may have to avoid the test because it uses magnetic fields and radio waves.

• CT scans are more widely available.

• MRI costs more than CT scans.

We recommend discussing any concerns with the prescribed test with your doctor. 

How Much Does an MRI Cost?

We have reviewed MRI charges from healthcare providers across Virginia and Maryland when evaluating auto accident and workers compensation claims for settlement or trial. 

MRI costs range from $500 to $4,000 or more, with an average charge of $1,000 to $2,000 in workers comp cases. 

The factors affecting how much your imaging costs include:

• Where you live or undergo the imaging

• The body parts scanned

• Contracts in place between the insurance company and the service provider

• Whether you receive additional medication or undergo other procedures during the MRI

When Does Workers Compensation Have to Pay for an MRI?

Generally, workers compensation laws require employers and insurers to pay for medical attention that is reasonable, necessary, and related to the work accident. For example, in Virginia, Code Section 65.2-603 details what insurers must offer and pay for.

However, the test for approval for a workers compensation MRI and related diagnostic procedures is more favorable to injured employees in our Commonwealth. The burden of proof is lower.

The Workers Compensation Commission has consistently interpreted necessary medical attention to include reasonable and necessary diagnostic procedures, such as medical imaging tests, even though the injured employee has not established the ultimate causation of the condition.

Indeed, the insurer must pay for a workers compensation MRI if you prove a possible causal relationship between the occupational injury and the Magnetic Resonance Imaging, even if the test reveals your condition is unrelated to the industrial accident.

Why is the Insurer Denying the MRI When My Treating Physician Says I Need It to Continue Treating for the Work Injury?

It can be frustrating to find out that you must reschedule medical imaging because the workers compensation insurer still needs to authorize the MRI.

Equally frustrating is that the insurer may ignore your requests for MRI approval and not tell you the reason for the denial. 

That said, we have identified several reasons that insurers deny or delay the authorization of diagnostic imaging in workers compensation cases:

• The insurance adjuster has not received the order from your treating physician or the MRI facility. Before you leave each appointment, we recommend asking your doctor’s office for a copy of the office visit report, written work restrictions, and orders and prescriptions.

• The insurance adjuster sent approval to the wrong fax number or email for the MRI facility.

• You have not filed a claim for benefits or received a Workers Compensation Award Letter; therefore, the insurer has no legal obligation to pay for the MRI or other medical treatment even though it knows you have a valid claim. Learn how to file a workers comp claim here.

• The claim adjuster wants to review your file or send it to another doctor for a second opinion or “peer review” before deciding to pay for the MRI. This tactic is sometimes called utilization review. In our experience, this doctor hired by the insurance carrier is more likely to render an opinion that is unfavorable to your claim.

• The adjuster wants to save the insurer money by denying MRI approval, hoping you will give up the claim or accept a low-ball settlement offer. (Here is a hint: never accept the first offer).

• An Independent Medical Evaluation (IME) doctor hired by the insurance company says your work injury healed weeks ago, and ongoing complaints are related to a pre-existing condition; therefore, the insurer denied the MRI and will force you to prove your claim at a hearing.

It is possible to overcome these problems and get approval for a workers comp MRI. 

Can the Insurance Carrier Dispute the Need for the MRI Even Though I Have a Workers Comp Award Letter?

Yes, the insurer may deny the order for Magnetic Resonance Imaging even when you have an award for lifetime medical benefits.

Read the fine print on the Award Order. You will see that the insurer is responsible for lifetime care that is reasonable, necessary, and causally related to the occupational injury or illness.

These modifiers—reasonable, necessary, and causally related—allow the insurer to dispute any prescribed medical treatment, even if the Commission awards medical benefits. Therefore, the claim adjuster may deny the MRI and avoid a bad faith claim even though the insurer has paid for all treatments.

We find this situation unfair and unsatisfactory.

In addition, it often makes little business sense for the insurance companies to halt treatment. The insurer will likely spend any money they think they are saving by delaying the MRI on additional wage loss payments and health care. Delayed treatment can lead to increased disability or surgery when timely conservative care could have healed you.

How Can I Get the Workers Compensation MRI Approved and Scheduled?

A delayed diagnosis because of a denied MRI can prolong your recovery time and increase how long you are disabled from an occupational injury or illness.

Therefore, you want to be proactive in getting approval for the MRI. 

We recommend taking some or all of these steps to reverse a workers comp denied MRI into an approved medical imaging testing:

• Find out the order’s status: Ask your doctor’s office if and when it sent the MRI order to the claim adjuster and the facility. See what response your doctor has received or if it awaits an answer.

• Ask the MRI facility which employee handles obtaining authorization and approvals from workers comp. Give that person’s contact information to your claim adjuster. In addition, you should provide the adjuster’s contact information and a copy of the doctor’s order to the testing facility.

These first two steps determine if the insurer has denied the MRI or has not acted yet. Sometimes (more often than not), the insurance adjuster is overworked with too many claim files and putting out fires as they spring up. Therefore, approving medical imaging takes a backseat to other claims.  

If these steps do not lead to the insurer responding, or if you find out the claim adjuster will not approve the MRI, then we recommend:

• Filing with the Commission a change-in-condition claim seeking authorization and approval of the MRI.

• Obtaining copies of all your medical records related to the work injury. Claims for authorization and approval of medical attention turn on the reports, not your testimony. Therefore, you must have written evidence to win your claim.

• Asking your doctor to write a report explaining the MRI is needed to determine if there is a relationship between your complaints and symptoms and the work accident. This opinion is crucial to your case because it provides evidence that the Commission can rely on to find you met the judicial standard for authorization of the diagnostic imaging.

• Using pretrial discovery to force the insurer to explain its defenses. Standard discovery tools include interrogatories, requests for production, and depositions. If the insurance company does not have a reasonable defense to the claim for approval, you can ask the Workers Compensation Commission to award sanctions against it.

• Trying to resolve the MRI dispute informally using issue mediation provided by the Commission’s Alternative Dispute Resolution (ADR) Department.

• Presenting your case at trial (learn about workers compensation hearings here). Although medical evidence is more important than testimony from you and witnesses in claims for MRI approval, your live testimony about how your symptoms have developed since the occupational injury can help you win a close case.

Suppose the insurer continues to deny the MRI after litigation. In that case, the Commission will hear evidence on your claim and decide whether the workers comp insurance company must approve this diagnostic procedure.

How Long Does It Take to Resolve a Dispute Over the MRI?

If the insurance carrier plans to approve the MRI, you should hear back within seven to 21 days of your follow-up requests.

However, you may have to litigate the issue if the insurer denies authorization or fails to respond.

If so, it could take 30 to 90 days to get a decision from the Commission, and it will only come after the parties submit written briefs or present their case at trial.

Can I Get the MRI Without Approval from the Workers Comp Insurer?

Maybe.

Most medical imaging facilities will only complete the MRI with insurance approval because the facility wants to ensure it gets paid. 

However, if you run into this situation, you may be able to get the MRI without approval if:

• You pay for the procedure out of pocket. Keep the receipt because you can file a claim seeking reimbursement from the insurer.

• You have other insurance coverage, such as private medical insurance, Medicaid, or Medicare, that pays for the MRI. This is okay; however, you may have to deal with potential lien or Medicare or Medicare Advantage conditional payment issues when negotiating a settlement.

• The MRI facility agrees to provide the care on a lien basis. This arrangement is more common in personal injury actions; however, we have seen it work in some occupational injury cases.

Then you can use the imaging results to continue your treatment and analyze your claim’s value. For example, if the MRI suggests you need a spinal fusion, you can seek significantly more monetary damages and a higher settlement amount than if the diagnostic procedure shows nothing.

Get Help Obtaining Approval for Your Workers Compensation MRI

All you want is to schedule the MRI to figure out how bad your work injury is and what treatment you need to heal and recover so you can return to work.

But the workers compensation insurer has denied the MRI your physician ordered.

And now everything is at a standstill.

Fortunately, you could get workers comp approval for Magnetic Resonance Imaging if you suffered a compensable injury. When the medical evidence shows that the MRI will help determine whether the cause of your symptoms relates to the occupational injury, the employer and its insurer must pay for the medical imaging.

Contact us to discuss how we can help you get insurance approval for a denied workers compensation MRI.

See why thousands of others in your position have asked us to represent them. And how we can get results for you.