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Navigating Workers’ Compensation Medication Denials: A Guide to Your Rights and Remedies

Matthew Mosher Feb. 8, 2024

When an employee sustains a workplace injury, access to appropriate medical treatment is vital for a speedy and effective recovery. However, there are instances where workers' compensation claims, specifically those related to medication, face denials. In this blog post, we'll delve into the common reasons behind medication denials and outline the steps you can take to address this issue and secure the treatment you need.

Understanding Medication Denials:

Workers' compensation medication denials can occur for various reasons, often leaving injured workers without the necessary prescriptions to manage pain, reduce inflammation, or promote healing. Common reasons for medication denials include:

  1. Formulary Restrictions: The NYS Workers’ Compensation Board has implemented a Drug Formulary requiring all physicians to follow for prescribing medication. Your doctor must start by prescribing a medication that is listed as a First Line medication for your medical needs.  If the doctor prescribes a Second Line medication without a medication being trialed from the first line of medications, the request will be denied.

  2. Lack of Medical Necessity Documentation: Insufficient documentation regarding the medical necessity of the prescribed medication can be a reason for denial.  Your doctor must provide clear and comprehensive evidence supporting the medical necessity for the prescribed medication.

  3. Treatment Outside of Work-Related Injury Scope: If the prescribed medication is deemed unrelated to the work-related injury, the insurance company may deny coverage. It's essential to establish a direct connection between the medication and the workplace incident.

Medication requests are governed by the New York State Drug Formulary.  Providers must request access from New York State in order to gain access to the system.   Many medications contained in and consistent with the Formulary do not require prior authorization from the Insurance Carrier.  All other requests for medications must be submitted through a Medical Portal between the Physician’s office and the Insurance Company.  The initial request through the Portal is a Level 1 request.  The Insurance company will review the request and can either approve or deny the request.  If approved, the medication will be available for pickup at your pharmacy.

If the request is denied by the insurance carrier at Level 1, it is sent to a Level 2 review by a medical professional in the employ of the Insurance Carrier.  This Level 2 review may result in an approval or result in a continued denial of your medication request. 

If the Medication request is denied at the First and Second Levels of Review by the Insurance carrier, your doctor can request a Level 3 review where requests are evaluated by the NYS Medical Directors Office.  Encourage your Provider to submit all denials to Level 3 for review because there is a reasonable chance that the Medical Directors Office overturns the Carrier’s denial if properly supported in the medical request by your doctor.

If the Medical Directors Office upholds the denial, that determination is final. The Workers Comp Board does not permit review of these determinations by a Workers Compensation Law Judge.  If the MDO approves the request, you will be able to obtain the requested medication.

Steps to Take When Facing Medication Denials:

  1. Consult with Your Treating Physician: Start by discussing the denial with your treating physician. They can often provide additional documentation and/or clarification regarding the medical necessity of the prescribed medication. Your doctor's input is crucial in addressing the denial.  They will need to refile the request at that point with additional information.

  2. Seek Legal Counsel: Consulting with an experienced workers' compensation attorney is essential when facing medication denials. An attorney can review your case, advise you on your rights, and guide you or your provider through the process on the basis of the denial.

  3. Explore Alternative Medication Options: Work with your treating physician to explore alternative medications that may be in Medical Formulary. Finding acceptable substitutes can be a practical solution to overcome denials.

Facing a Workers' compensation medication denial can be frustrating, but it's crucial to take proactive steps to address the issue. By working closely with your treating physician and seeking legal guidance, you can navigate the process and fight for the medical treatment you need to recover from a work-related injury.  Often times, if the Insurance company is fighting to deny your medication, they will often be denying medical treatment and lost time next.  Remember, your health and well-being are top priorities, and you have rights to ensure that you receive the appropriate medical care.