You were injured at work, you saw a doctor, and they recommended an MRI or a major procedure. You might assume that because your injury happened on the job, this recommended treatment is automatically covered.
Unfortunately, many injured workers in North Carolina quickly discover that getting a recommended medical procedure authorized by the insurance company is not always automatic. It is incredibly frustrating to deal with pain while waiting weeks for a decision, or to hear that your insurance carrier has questioned your doctor’s recommendation.
If you are facing a workers’ comp delayed treatment situation, or if you have been told your procedure was denied, you are not out of options. While workers’ compensation insurance companies can, and do, sometimes refuse to pay for expensive diagnostic tests or surgeries, these decisions are not always the final word. Understanding how the approval process works under North Carolina workers’ compensation law can help you navigate this challenging period.
Will Workers’ Compensation Always Pay for an MRI or Surgery?
The Short Answer: No, workers’ compensation does not automatically pay for every recommended MRI or surgery. In North Carolina, the insurance carrier is only legally required to pay for medical treatments that are deemed “medically necessary” to effect a cure, provide relief, or lessen your period of disability under N.C.G.S. § 97-25.
Under the North Carolina Workers’ Compensation Act, your employer’s insurance carrier has a legal obligation to provide necessary medical compensation. However, because specialized diagnostics like a workers’ compensation MRI and orthopedic procedures like a workers’ comp surgery approval are costly, insurance companies utilize a system of pre-authorization.
Before a provider can perform a major non-emergency procedure, they must submit a request for workers’ comp medical authorization for most insurance companies. If the insurance company believes the treatment is not directly related to your work injury, or if they believe a less expensive treatment should be tried first, they can temporarily or permanently deny the request.
Why Might an MRI or Surgery Be Delayed or Denied?
The Short Answer: The most common reasons for a denied MRI workers’ compensation request or a delayed surgery approval include questions about medical necessity, incomplete clinical documentation, requests for second opinions, or the insurance carrier requiring you to complete “conservative therapy” first.
When an insurance carrier holds up or denies your treatment, it is rarely a personal attack. Usually, the delay is driven by the insurer’s internal guidelines and cost-control measures. However, sometimes the insurance company is using a tactic and your should consult an attorney in either situation.
Here are the primary reasons why these approvals stall:
- The “Conservative Treatment” Requirement: Insurance guidelines often dictate a step-by-step approach to care. For example, before approving a costly spine surgery or even a high-tech scan, they may require you to undergo several weeks of physical therapy or take anti-inflammatory medications first.
- Lack of Supporting Documentation: If your medical records do not clearly establish a direct link between the work accident and the need for the specific surgery, the insurer’s peer review team may flag it.
- Utilization Review (UR): Insurance companies use third-party companies to conduct a “utilization review” under G.S. 58-50-61. These reviewers compare your doctor’s recommendation against standardized medical guidelines to decide if the treatment is appropriate.
- Independent Medical Examinations (IME): The carrier may request that you see a doctor of their choosing for a second opinion to evaluate whether you truly need surgery.
- Pre-Existing Condition Questions: If you have a history of back pain or a previous joint injury, the insurer may argue that the proposed surgery is treating an old, non-work-related issue rather than the new work injury.
If you find yourself in a situation where the insurance company’s doctor disagrees with your treatment plan, it can feel incredibly discouraging.
Does a Denial Mean You’ll Never Receive Treatment?
The Short Answer: Absolutely not. An initial denial or a workers’ comp delayed treatment notice is a hurdle, not a dead end. Many denied treatments are eventually approved after providing additional medical evidence, clarifying the records, or taking formal legal action.
If your treatment is denied, the decision can be challenged. In North Carolina, the North Carolina Industrial Commission (NCIC) oversees all workers’ compensation disputes.
To turn a denial around, your legal and medical teams will generally look at these avenues:
| Resolution Pathway | How It Works |
| Submitting Additional Evidence | Your treating physician can submit additional clinical notes, clarifying why conservative measures failed and why the MRI or surgery is crucial. |
| Requesting an Administrative Motion | Under N.C.G.S. § 97-25(f), your attorney can file an administrative motion with the Executive Secretary of the Industrial Commission for a quick ruling on medical treatment disputes. |
| Filing Form 33 | If the administrative route doesn’t resolve the issue, you can file a Form 33 (Request that Claim be Assigned for Hearing) to have your medical dispute formally heard by a Deputy Commissioner. |
Understanding what steps to take next is key to keeping your recovery on track. If your entire claim or a vital part of your treatment has been rejected, check out our resource on Workers’ Comp Denied? Here’s What to Do.
What Should You Do If Your Symptoms Are Getting Worse While Waiting?
The Short Answer: If your condition deteriorates while you wait for authorization, your immediate priority must be your health. Report the changes to your treating physician, document every symptom carefully, and keep your legal team informed.
Waiting for an insurance company to decide while you are living with severe pain is exhausting. To protect both your health and your legal rights during a delay, keep these practical steps in mind:
- Keep Your Doctor Informed: If your pain increases or you develop new symptoms (like numbness, tingling, or weakness), tell your doctor right away. They need to document these changes in your medical file, which provides the precise clinical evidence needed to push the insurance company for an expedited review.
- Do Not Skip Your Scheduled Appointments: Even if you feel like you are just running in circles, missing appointments can harm your case. The insurance company might claim that your condition must not be that severe if you are missing visits.
- Be Mindful of the Risks of Waiting Too Long: Delaying care or failing to report changes promptly can complicate your recovery and your claim. For more context on why consistent care matters, read What Happens If You Delay Medical Treatment After a Work Injury?
- Learn About Changing Doctors: If you feel your current doctor is not taking your worsening symptoms seriously, you may have options under North Carolina law to request a change of physician. Read our breakdown on Can I Choose My Own Doctor in a North Carolina Workers’ Comp Case?
When Should You Speak With a Workers’ Compensation Attorney?
The Short Answer: You should speak with a workers’ compensation attorney if your required surgery has been denied, if your MRI is delayed for more than a few weeks despite worsening pain, or if the insurer has stopped paying for your authorized treatments altogether. Candidly, you probably need a free consultation even if your care is being authorized, as you still may be entitled to more than meets the eye.
Navigating the administrative rules of the North Carolina Industrial Commission while trying to heal is a heavy burden. An experienced legal team can handle the paperwork, file the necessary motions, and communicate directly with the insurance adjuster on your behalf.
You may want to seek guidance if:
- The insurance carrier refuses to authorize a specialist visit.
- You are facing a complex pre-existing condition dispute.
- Your symptoms are deteriorating, and you need to know: What If My Work Injury Gets Worse Over Time?
Frequently Asked Questions
How long does workers’ comp take to approve an MRI?
While simple treatments may be authorized in a matter of days, complex diagnostics like an MRI can take anywhere from a few days to several weeks if they are sent to a utilization review board. If the delay is unreasonable, your attorney can file an expedited motion with the Industrial Commission under N.C.G.S. § 97-25.
Can I pay for my own MRI?
Paying out-of-pocket or using private health insurance is generally discouraged while your workers’ compensation case is active and accepted, as it can complicate reimbursement and billing. Medical providers are prohibited by Industrial Commission rules from billing you directly for work-related treatments once they know a workers’ comp claim is filed, unless the claim is formally denied (Form 61).
What if my doctor disagrees with workers’ comp?
If your authorized treating physician states you need surgery, but the insurance company’s utilization review denies it, a conflict exists. You do not have to accept the insurance company’s decision. Your attorney can formally appeal the denial to the Industrial Commission to seek an order forcing the carrier to pay.
Can surgery be approved later?
Yes. It is very common for a surgery that was initially denied to be approved later. This often happens after you complete a required course of conservative therapy (like physical therapy or injections) and your doctor documents that your symptoms have not improved. It also often happens once you hire an attorney to fight for you.
Don’t Let The Waiting Game Wear You Down
Waiting on a workers’ compensation denied treatment decision or dealing with constant delays is incredibly stressful when you are just trying to get back on your feet. It is important to remember that a “no” from an insurance adjuster is often just the beginning of a process, not the final word on your care.
Stay engaged with your medical team, make sure your symptoms are thoroughly documented, and do not lose hope. If you are struggling to get the critical medical treatments you need to heal, you do not have to fight the insurance company alone.
Contact Shankle Law Firm today for a free consultation. Let our dedicated team stand up for your rights so you can focus on your recovery.
*Please Note – The content on this website is for informational purposes only and does not constitute legal advice. Viewing this site, using information from it, or communicating with Shankle Law Firm, PA through this site does not create an attorney-client relationship. For legal advice tailored to your situation, please contact us directly at (704) 370-1212.
