The claimant sustained an admitted work injury to his lower back and then relocated to Texas. The provider in Texas submitted a request for prior authorization for surgery. The adjuster issued a denial that simply stated the surgery was denied.
The denial did not comply with Rule 16. The claimant then filed a motion asking the Director to conclude that the prior authorization request was not properly denied and thus, was deemed authorized by operation of law.
Respondents argued that the “prior authorization request” was not a proper prior authorization request as it...
The Director held that the threshold issue was whether the prior authorization request was a complete request under the applicable rules. The Director noted the Form WC 188 is optional but if not included, then the provider must clearly label the request as a prior authorization request. This labeling is not merely a formality. Its purpose is to put the payer on notice of the quick deadline to respond. The Director held there are factual issues regarding whether this request complied with the legal requirements.
The Director held that the request also did not explain why the proposed procedure was reasonable, necessary, and related to the work injury.
Lastly, the Director held that the request did not identify the applicable Medical Treatment Guidelines and also did not discuss the required psychological screening. It also did not explain why there was a deviation from the guidelines or the emergency nature of the proposed procedure to allow the deviation.
The Director concluded that the request was not a complete prior authorization request per the applicable rules. Thus, the claimant’s motion was denied.
Andrade v. M.A. Mortenson Co., W.C. No. 5-318-810 (Director’s Order June 2026).
Want to know more? Contact Joshua Dillard at jdillard@pollartmiller.com
