GQ Corner
Q. We have a current PLN-11 on file based on the outcome of a peer. We also received a request for surgery which although approved, unfortunately has now expired. My question is based on the carrier’s extent dispute; do you feel there is a basis as to a dispute of the UR approved procedure once the approval period is current?
A. If there is a PLN-11 on file disputing the condition giving rise to the need for the medical treatment not only do you have a basis for denying the bill, in the absence of a Designated Doctor determination to the contrary, you should deny the bill. Preauthorization is not a determination of extent and is not a guarantee of payment. If there is evidence that the URA made its initial determination based upon a review of medical records that were less than complete (as is often the case), then the URA should only extend the authorization period after a review of the totality of the relevant medical records (including the peer review).
Q. I have an employee that was sent to the clinic for possible exposure to Covid-19. Eight other employees were tested resulting in 4 positive and 4 negative. The claimant went to the clinic and because she had no symptoms the clinic did not test her. The clinic used diagnosis code V01.79, Z20.828 / exposure to Covid-19. Would you recommend a PLN-1 to dispute? If so, what dispute language would be recommended? The claimant’s date of injury is 6/10/20 and was released to full duty 6/18/20.
A. The employee tests negative and has no symptoms. This is a “no injury” case.
I am going to give you language. It is NOT to be used for first responders and I am assuming that this individual is not a first responder or public safety employee. The language to be used is as follows: We understand that you have reported to your employer that you believe that you might have been exposed to SARS-CoV-2, the virus responsible for causing the disease known as COVID-19. Further, we understand that you have indicated that such exposure was in the course and scope of your employment. During the course of our investigation we received information that you have been tested and that the test for COVID-19 has come back negative. If this is incorrect, please let us know immediately. It is also our understanding that you have not yet been diagnosed with any other occupational disease. The claim was reported to [Insurance Carrier] as an exposure only. Texas statutes govern various aspects of exposures to contagious and reportable viruses (i.e., exposure to the virus, SARS-CoV-2) and claims involving the development of the disease itself (i.e., development of COVID019). Different statutes govern each type claim and depend upon the type of employee. Workers’ compensation are payable only for a “compensable injury” as that term is defined in the Texas Workers’ Compensation Act (TWCA). Except in limited circumstance not applicable her, benefits under the TWCA are not payable for an exposure to a virus that may only possibly lead to injury or disease. Additionally, to be entitled to workers’ compensation benefits for a diagnosed disease, the Texas Workers’ Compensation Act requires that such disease must not be an “ordinary disease of life” and it must have been contracted during the course of employment with your employer. At this point, based upon the information provided to us, there is insufficient evidence of any injury (i.e., damage or harm to the physical structure of your body or occupational disease) that arose out of your employment and from an activity that has to do with and originates in the work, business, trade, or profession for your employer and which was performed by you while you were engaged in or about the furtherance of the affairs or business of your employer. Please notify us immediately should you receive a confirmed diagnosis of a disease so that a further evaluation of compensability can be determined.
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