Surgery often feels like the turning point in recovering from a workplace injury, so a refusal to cover it may leave you in pain and unsure what comes next. Recognizing the standard Ohio law sets for approving medical treatment puts you in a firmer position to respond.
Meeting Ohio’s three-part approval test
Your doctor’s recommendation alone does not guarantee payment for the operation. To qualify, the procedure must:
- Be reasonably related to the conditions allowed in your claim
- Be reasonably necessary to treat those conditions
- Have a medically reasonable cost
The first requirement turns on which diagnoses workers’ comp has accepted as work-related. Surgery that could ease your pain still fails that part of the test if it would treat only a condition outside your claim.
Reviewing your surgery request
Before a nonemergency operation, your doctor submits a written request. For state fund claims, a managed care organization working with the Ohio Bureau of Workers’ Compensation reviews it. If your employer is self-insured, it has 10 calendar days to respond after receipt, or the surgery counts as approved.
When the managed care organization asks for more medical records, your doctor has 10 business days to send them. If they do not arrive in time, it can deny the request on an active claim or dismiss it on an inactive one.
Challenging a denial
For a state fund claim, you have 14 days after the denial arrives to send that organization a written dispute. An independent review usually follows before the bureau issues an order, and once it reaches you, you have 14 days to appeal to the Industrial Commission of Ohio.
When a self-insured employer refuses the surgery, you file a motion requesting a hearing with the commission. Your doctor can support either challenge by addressing the stated reason in a report. If the decision rests on a diagnosis your claim does not include, you may ask to add it before seeking approval again.