If you need surgery after a work injury, but the request is denied, it can feel hopeless. Workers’ compensation is supposed to approve all reasonable and necessary medical treatment. This should be based on the recommending physician, but insurance companies often push back or deny surgery to try to save money. This can leave you unsure of what to do next.
At Underwood Law, LLC, our Georgia workers’ compensation attorneys know how to help you. We push back against denied surgery requests and seek the medical benefits you are owed. You are not alone in this stressful process.
Why Workers’ Comp Denies Surgery in Georgia
Even when your authorized treating physician recommends surgery, the insurance company may deny it for several reasons:
- They Claim the Surgery Isn’t Medically Necessary: Insurers often argue that conservative treatment, like physical therapy or injections, should continue instead of surgery.
- They Say Your Injury Is Pre‑Existing: If you have prior back, knee, or shoulder issues, insurers may blame your condition on old injuries rather than your work accident.
- They Dispute the Connection To Your Job: This is common with repetitive‑motion injuries or gradual‑onset conditions.
- They Rely on an IME or Peer Review: An independent medical exam (IME) doctor hired by the insurer may disagree with your treating physician.
- They Claim You Didn’t Follow Proper Procedures: Missing appointments, gaps in treatment, or delays in reporting your injury can give insurers excuses to deny surgery.
A denial doesn’t mean the end of your claim. It simply means you need to take the next steps strategically.
Step 1: Get the Denial in Writing
Georgia workers’ comp insurers must provide written notice explaining:
- Why the surgery was denied
- What evidence they relied on
- Whether they used an IME or peer review
- What additional information they want
This written denial is essential for appealing the decision or requesting a hearing.
Step 2: Talk to Your Authorized Treating Physician
Your authorized treating physician is the most important voice in your case. After a denial:
- Ask your doctor to provide a detailed explanation of why surgery is necessary.
- Request updated medical records, imaging results, and treatment notes.
- Make sure your doctor submits a clear, written recommendation for surgery to the insurer.
Strong medical documentation is often the key to overturning a denial.
Step 3: Request a Hearing With the State Board of Workers’ Compensation
If the insurer refuses to approve surgery, you can file a WC‑14 and request a hearing before an Administrative Law Judge (ALJ). At the hearing, the judge will review:
- Your doctor’s recommendation
- The insurer’s denial
- Medical records
- IME reports
- Testimony from you and medical experts
The judge can order the insurer to authorize and pay for the surgery if the evidence supports your need for treatment. Hearings for Georgia workers are typically scheduled within a few months, though timelines vary.
Step 4: Consider Filing for a Medical Conference or Mediation
Georgia offers alternative dispute‑resolution options that may resolve the issue faster:
- Medical conferences allow doctors and attorneys to discuss treatment needs directly.
- Mediation can lead to agreements without a formal hearing.
These options are often quicker and less adversarial than a full hearing.
Step 5: Protect Yourself From Insurance Company Tactics
When surgery is denied, insurers may try to:
- Push you into returning to work early
- Suggest alternative treatments that won’t fix the underlying problem
- Use IME doctors to undermine your treating physician
- Delay communication to stall your claim
You are not required to give recorded statements, and you should be cautious about signing any documents without understanding their impact.
Step 6: Keep Following Your Doctor’s Treatment Plan
Even while fighting the denial, continue:
- Attending appointments
- Completing physical therapy
- Taking prescribed medications
- Documenting pain levels and limitations
Gaps in treatment can weaken your case and give insurers more ammunition.
A Georgia Workers’ Comp Attorney Will Help You Fight for the Surgery You Need
A denial is not the last step in the process. There are ways to contest denied surgery requests and seek the benefits you’re entitled to under Georgia workers’ compensation law.
Our team at Underwood Law, LLC are ready to help with your needs. Contact us today for a consultation.
