Medical Treatment Denials in Virginia Workers’ Comp

What to Do When Workers’ Comp Won’t Approve Your MRI, Surgery, Therapy, or Referral

The insurance company can deny a specific MRI, surgery, course of therapy, or referral even after it has accepted your claim, and even when you have an Award Order for lifetime medical benefits. It has three grounds that Virginia law recognizes: the treatment isn’t related to the work injury, isn’t reasonable or necessary, or wasn’t ordered by your authorized treating physician. And nothing in the Virginia Workers’ Compensation Act makes it answer your doctor’s request for authorization by a set date.

You are not stuck waiting, though. If you have an Award Order, a Petition for Medical Treatment gives the insurer seven calendar days to approve or deny the request, and if it stays silent the Commission may schedule a telephone conference. If you don’t have an award yet, a claim naming the treatment starts a different clock on the insurance company’s response. I explain both below, along with how to tell a real denial from a request for authorization that’s sitting in an adjuster’s inbox.

If the insurance company says the injury itself isn’t covered, that’s a denied claim, which my page on denied workers’ compensation claims covers; this page is about an MRI, surgery, therapy, or referral the carrier won’t approve in an accepted or awarded claim.

First, figure out whether your treatment is actually denied or you’re just waiting.

“Pending” isn’t a decision. It just means nobody has said yes or no yet. Before you treat it as a denial, find out where the request actually is. A lost fax and a real treatment denial are different problems, and you handle them differently.

Ask your doctor’s office what exactly it ordered and when, where it sent the order and visit note (the adjuster, the facility, or both), whether anyone has answered, and whether the insurance company asked for anything more.  

I also recommend asking the referred-to facility who handles workers’ comp authorizations, and giving that person the workers’ comp adjuster’s name and number. Then ask the adjuster to put the referral status and any reason for refusal in writing. Get a copy of the order and the visit note before you leave any appointment; the provider must furnish a copy of any medical report to you on request (Va. Code § 65.2-604(A)).

Here’s what “under review” usually means inside the adjuster’s file:

The adjuster is comparing the prescription or referral order against the injuries the carrier accepted or the Commission awarded. If the treatment your doctor ordered relates to the accepted or approved injuries, the carrier has several things it can do before authorizing it: request your medical records from the provider, hire a physician to review those records without examining you, or require you to attend an independent medical examination (IME) under § 65.2-607(A). None of those steps, by itself, means the adjuster will deny the treatment.

None of these steps comes with a deadline for the insurance company to act. If you can’t get an answer from the carrier, the Commission’s own advice is to contact it for help rather than wait around for a denial letter, and I agree.

What the insurance carrier can dispute when it comes to medical treatment, and what it can’t

The statute itself doesn’t say much. § 65.2-603(A)(1) says that “as long as necessary after an accident,” your employer must furnish, free of charge, a physician you choose from a panel of at least three selected by the employer, “and such other necessary medical attention.” It doesn’t say “reasonable” or “causally related”; those words come from Court of Appeals decisions applying it, and they’re usually the words on your Award Order.

The test the Commission applies is this: the employer is responsible for medical attention if “(1) a causal relationship exists between the workplace accident and the treatment, and (2) the attending physician deems it necessary” (Vital Link, Inc. v. Hope, 69 Va. App. 43 (2018), slip op. at 6–7). When the carrier disputes care, you generally have the burden of showing that the treatment is causally related to the accident, necessary for the compensable injury, and recommended by an authorized treating physician (Portsmouth (City of) School Board v. Harris, Record No. 0026-11-1 (Va. Ct. App. July 19, 2011), slip op. at 5). But Virginia workers’ compensation law recognizes a distinction: “[w]here the treating physician has prescribed specific medical treatment, the burden of proof shifts to the employer to show that the medical treatment is unreasonable or unnecessary, and that it is relieved from the mandate of the Virginia Workers’ Compensation Act.” Hogan v. Misener Marine Constr., Inc., VWC File No. 128-80-49 (Feb. 25, 1993).

When I read a denial letter, or the insurer’s answers to my interrogatories and requests for production during discovery, I’m trying to figure out which of three questions the carrier is really raising. Almost every medical-treatment dispute comes down to one of them:

1. Is this care for the work injury?
2. Has your treating physician explained why you need it?
3. Did the request come from an authorized treating physician, from a specialist or facility that physician referred you to, or a provider you saw on your own for a second opinion?

“It’s not related to the work injury.” Here the carrier may rely on a medical opinion from the records review or IME described above, or even a throwaway line in your treating doctor’s notes, that your current problem is degenerative, preexisting, or the product of something that happened after the accident. Or it may argue that your records don’t connect the care to the accident. Either way, you fight back the same. Ask your doctor to say, in the note or a separate questionnaire, how the symptoms and the proposed care connect to the accident, and to address any competing explanation the carrier raises.

“It’s not reasonable and necessary.” You’ve probably seen the language already: surgery is “premature”; therapy “has plateaued” or is “no longer showing improvement.” Your treating physician’s opinion “is entitled to great weight, although the commission is not required to accept it” (United Airlines, Inc. v. Hayes, 58 Va. App. 220, 238 (2011), slip op. at 13). When opinions conflict, the Commission adopts the view “most consistent with reason and justice” (Hayes, slip op. at 13). The carrier can respond with a competing opinion, or it can argue that your evidence doesn’t meet the burden. And the Court of Appeals has said a vague prescription doesn’t meet it: when a treating physician prescribes something “unspecific, generalized, and generic,” you have to prove that the particular care is medically necessary (Portsmouth School Board v. Harris, slip op. at 8). So ask the doctor for the procedure’s purpose, the expected benefit, and why it’s needed now rather than later.

“It didn’t come from your authorized treating physician.” The insurer keeps some control over your medical treatment. It is only responsible for treatment from the doctor you chose from the panel (or the doctor the Commission found to be your authorized treating physician) and from the providers that doctor refers you to. If you went to a doctor on your own, the carrier can refuse to pay; the exceptions (§ 65.2-603(C)) and the rules for switching doctors are on my page about changing doctors in your workers’ compensation case, which also covers the adjuster who says the surgery is approved “but only with our doctor.”

What the carrier can’t do when it comes to medical care referrals. It can’t redirect your treating physician’s referral: “neither the employer nor its insurance carrier may limit the treating physician in the medical specialist, or treating facilities to which the claimant may be referred for treatment” (Jensen Press v. Ale, 1 Va. App. 153, 158 (1985), quoting Beauchamp v. Cummins & Hart, 60 O.I.C. 37, 39 (1982)). And it can’t treat its own silence as an answer: a lack of response isn’t a written approval, and it isn’t a formal denial either. It can require an IME, but only one per medical specialty without the Commission’s authorization (§ 65.2-607(A)), and you should go, because refusing or obstructing it suspends your compensation and your claim until you comply unless the Commission finds the refusal justified (§ 65.2-607(B)). An IME is an opinion, not a ruling; my page on the defense independent medical examination covers how to handle it.

If you’re the one hesitating about the recommended care, that’s a different question with its own statute, § 65.2-603(B), and my page on refusing medical treatment or surgery explains the consequences.

Diagnostic tests, including MRIs: the rule works in your favor

A test or procedure ordered to find out what’s wrong is treated differently from treatment itself, and this trips up a lot of adjusters. You don’t have to prove the condition is work-related before the test that’s meant to answer that question; the records only need to show a possible connection. The Court of Appeals has held that “necessary medical attention” includes “reasonable and necessary diagnostic procedures, even though ultimate causation of the condition has not been firmly established and even if the procedures reveal that the condition is not in fact related to the compensable injury.” The carrier owes the test when it is reasonable and necessary, your approved treating physician authorized it, and the medical records “indicate a possible causal connection” between your condition and the compensable injury. The reasonable-and-necessary element “is proven by a showing that the diagnostic procedure was recommended by the claimant’s approved treating physician” (Herbert Clements & Sons, Inc. v. Harris, 52 Va. App. 447, 457–58 (2008)).

The procedure in that case was a diagnostic arthroscopy, so the rule isn’t limited to imaging; it turns on the procedure’s purpose. A normal result doesn’t undo the carrier’s obligation to pay for it. And the Commission’s own precedent, noted by the Court, shifts the burden when your treating physician prescribes a specific diagnostic procedure and the carrier’s only objection is that it isn’t reasonable or necessary: then the carrier must prove that (Clements, 52 Va. App. at 458 n.11, citing Rojas v. Residence Inn, VWC File No. 194-67-09 (Sept. 26, 2003)).

To win the dispute in litigation, or avoid litigation altogether, get an order for the diagnostic imaging or test from your treating physician, along with a note explaining what the test will uncover and how it may connect to your work accident, even tentatively.

If the insurance company won’t approve the test and you can’t wait. Most imaging facilities won’t scan without authorization, but you have options. You can pay out of pocket and file a claim for reimbursement as part of the workers’ compensation case. You can run it through other coverage. A private health plan may assert a lien, and if the employer self-funds the plan, ERISA governs that lien. Medicaid may assert one too, though how far it can enforce it against a workers’ comp recovery is a disputed question. Medicare will demand repayment of its conditional payments at settlement. Or, less commonly in comp than in personal injury, the facility agrees to bill on a lien against your claim. Any of these gets you the result you need so treatment can move forward, and the reimbursement claim goes on the same petition or claim form as the authorization dispute.

A note about repeat testing: Did you have the same test with a different medical provider recently? If so, the insurer may not have to pay for a repeat test performed within the past 60 days unless the new physician makes a good faith attempt to use those past results. If your new specialist wants a fresh MRI, ask them to explain why in writing before the order goes out.

The same rules apply to diagnostic surgery, such as an exploratory arthroscopy to determine the cause of your knee or shoulder pain. In practice, though, the Commission wants more explanation before it orders surgery than before it orders an MRI, and I prepare for that. For example, I have handled many claims where the surgeon wanted to perform an arthroscopic knee surgery to confirm a meniscus tear that did not show up on imaging. I asked the surgeon to explain what the imaging shows and doesn’t show, and why exploratory surgery is a reasonable and necessary way to determine the cause of the injured employee’s symptoms.

If physical therapy is what the injured employee needs, I ask for a written order that defines the course of therapy and how it alleviates symptoms, even temporarily.

How long the carrier has, and what “medical authorization pending” actually means

Since nothing in the Virginia Workers’ Compensation Act or the Commission’s Rules makes the carrier answer your doctor’s request by a set date, you have to put the dispute in front of the Commission. Otherwise, you risk waiting weeks or even months for approval, because an adjuster’s promised date is not an enforceable deadline, no matter how many times it’s promised. I have lost count of the number of injured employees who retain me because the insurer has simply stopped responding to requests to authorize medical treatment – even for something as routine as physical therapy or a specialist referral. Part of the reason is financial: an approved MRI or surgery often forces the insurance company to raise its claim reserve.

You create deadlines for the carrier by filing a claim for benefits seeking authorization and payment or, if you have an award, filing a Petition for Medical Treatment. The next section walks you through that petition.

What to file to overcome a medical treatment denial, and what happens next

What you file depends on whether you already have an Award Order.

If you’re under an award: the Petition for Medical Treatment. The Commission launched this automated program in September 2025 and made it a permanent process after completing a multi-year pilot. It’s for exactly this situation: the insurer refuses to authorize medical treatment prescribed by a treating physician when you have already proven a compensable injury, and the employer has legal representation.

You fill out the form, attach the medical records supporting the request, and upload both through WebFile. Then Commission staff screen the petition for eligibility and, if it qualifies, send notice to the carrier to respond (Petition for Medical Treatment; form and instructions, Rev. 9/25).

The carrier then has seven calendar days to tell the Commission and you whether the care is approved or denied. If it’s approved, the Commission memorializes the approval. If there’s no answer, the Chief Deputy Commissioner or a designee may schedule a telephone conference with both sides. If it’s denied, the dispute is referred to the on-the-record or evidentiary hearing docket described below. 

The Chief Deputy Commissioner (currently James Szablewicz) usually handles these phone conferences, which are brief, lasting 10 to 15 minutes, tops. In my experience, he will press the insurer to approve the treatment when it has no plan to obtain contradictory medical evidence and no obvious basis for denial. That pressure alone resolves a good number of these.

If you do not yet have an Award Order, you can file a claim naming the treatment. Use the Commission’s Claim Form or WebFile. Check the form’s Other box, then write “authorization and payment of specified medical treatment/procedure,” followed by the exact procedure and the doctor who ordered it. This claim is known as an application for a “change in condition” under Commission Rule 1.2 (16VAC30-50-20(B)(1)). Include the medical report with the filing or, if you don’t have it yet, submit it as soon as you do. If you don’t file supporting evidence within 90 days of filing the claim, the insurer can move to dismiss the claim (Rule 1.3, 16VAC30-50-20(C)), though dismissal is usually without prejudice, which means you can refile when you get the report.

What the Commission does. It may order the carrier to state in writing whether it accepts the request or why it denies it (Rule 1.5, 16VAC30-50-20(E)(2)); read that order carefully, because it sets the deadline. The carrier’s response is a required report to the Commission and isn’t part of the hearing record (Rule 1.5; § 65.2-601.2(B)–(C)).

If the carrier accepts, the provider can schedule.

If it contests and the dispute isn’t resolved informally, it goes to one of three tracks (Rule 1.9, 16VAC30-50-20(I); 16VAC30-50-30(A)): issue mediation, which is free, needs no lawyer, and produces a binding written agreement if it works (Rule 1.9; Request for Issue Mediation); a decision on the written record when no material fact is in dispute, with 15 days from the Commission’s order for your statement and evidence and 30 days for the carrier’s reply (Rule 2.1, 16VAC30-50-30(B)); or an evidentiary hearing before a deputy commissioner, before which you can serve written discovery asking the carrier to state every ground for its denial and every medical opinion it relies on (Rule 1.8, 16VAC30-50-20(H)).

When the fight is over authorization of physical therapy or diagnostic imaging, the dispute often gets resolved within a month, unless the Commission has to issue a decision on the record. In those cases, the Deputy Commissioner assigned to the case usually enters an opinion within 30 days of submission of the written briefs. Evidentiary hearings are uncommon for these types of medical treatment denials, though they are sometimes needed, and when they are, expect the timeline to stretch out by months rather than weeks.

When the dispute is over an invasive procedure such as surgery, an evidentiary hearing is often necessary so the parties can engage in discovery and challenge the other side’s evidence before the hearing. Just as often, though, disputes about the causal relationship or necessity of surgery lead the parties to participate in settlement mediation and settle the case instead.

If your MRI, surgery, PT, or referral was denied this week

Start your free case review or call me at (804) 251-1620.

If we accept your case, send us two things: the denial letter, or a note that there isn’t one, and the doctor’s order with the visit note behind it.

From those, I can usually tell how the carrier will defend the medical treatment request, whether the Commission’s petition process fits your case, and whether a phone call to the adjuster or defense attorney or a filing this week is likely to fix the delay.