Quote:
Originally Posted by Nanc
Hey Tessa,
Sorry but this is a very long reply, but I wanted to address all your questions.
I do not know of any diagnosis codes my dr used. I do not have any work release letters as I was never released to go back to work. My RSD spread and pain got to where I just couldn’t keep up in my job. In other words, I could not bear the pain any longer. The SCS’s were implanted in June 2011 (revision in Nov 2011) and they enabled me to continue working for another year and a half. The RSD kept progressing and the SCS’s effectiveness was wearing off. I was not sleeping because of the pain, doing my job was taking longer because of my hand and arm pain, I was having these additional pain attacks in my head, side and foot that effected everything (including driving). With RSD in my leg and feet, it was hard to sit in one position very long. I had difficulty walking to the copier and workroom at work. I was finding mistakes that I was making in my job, which was not good when you handle all the finances and hr for the organization. The more I used my hands, the more they hurt! I could not take pain meds when I was working. The insurance carrier did not give any reason for covering one week of STD. They sent a check for that period and that is all. The denial letters just stated that I was not approved for benefits beyond that period -?? My claim’s manager was not my employer; my boss was the employer contact on my claim. I was not exactly assigned a “claims manager”. Our claims were processed as follows: the employee completed form, employer completed form and the physician’s statement (form) all sent in with a copy of my outdated job description. On the drs statement, he put “unknown” as the date expected to return to work. I think the thing that did me most harm is that my dr had me do the functional capacity evaluation (FCE) which stated I could do sedentary work. My job was pretty much classified as sedentary. This FCE did not test real working environment, it tested how much weight I could push, pull and lift. Where is that relevant in my type of job?? The girl who did the FCE made mistakes on it. I tried to contact her and she would not return any of my calls. My dr said he could not say I was totally disabled because the FCE said I could do sedentary level. He said he couldn’t make that determination, even when I showed him the letter my PCP wrote stating I was totally disabled and she advised me to apply for disability (she did for the last two years). HE screwed me over on this whole thing, which is why I am looking for a new PM dr. I wanted to have a new FCE done and checked around, all of them are done the same way…they do not test on the computer, etc.
I was initially contacted by a claims analyst. She never returned any of my calls. They received my initial claim 12/6/12 and my last day was 12/28/12. I had to train a temp to do my job since no one else there knew how to do anything I did. They denied my claim 1/18/13. I had to get a claims supervisor involved because the mishandling of my claim. They only requested records from my PM dr for two months…that is two visits! He changed practices 10/1/12, anything prior was at the old practice and I offered over and over to get these records and send them. They didn’t want them. They denied the initial claim based on the FCE and two months of records. Wasn’t surprised there! So in the appeal, I sent all medical records – from all visits to this PM and others I have seen, PCP, foot dr, neurologists, allergist, dermatologist, everything!! ALL of my medical records note RSD/CRPS of upper & lower extremities, trunk and head. Also sent the letter from my PCP and letter my PM wrote. PM would not say I was totally disabled, but he did say that the FCE did not test real working environment, that my RSD is progressing, that I am in the later stages of RSD and we have eliminated all treatment options, etc., it was a decent letter. When I received my SSD award letter, I forwarded it to them. To get SSD, you have to be unable to do any job. In my STD/LTD plan documents, I have to be unable to do any of the duties in my current job.
There was no return to work request from my employer. When I left 12/28/12, they said they would hold my position a max of 90 days. My RSD was progressing and I was getting worse even after the last day worked. I was denied STD and not getting paid. I could not get my 401k until my employment was terminated and needed it in order to keep our house. They would not release me so I resigned effective 3/4/13 due to my medical condition (I did receive confirmation that this would not interfere with my disability claim appeal as they go by disability date).
I do not know what more could be supplied to them in the next appeal to make them overturn their decision ??
Thanks for your reply and help! What a stressful mess this is!
Nanc
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"Hey" to you Nanc,
So, first thing I would do is gather all the records from your doctors and also request copies of all documentation provided to your STD/LTD claims department from your physicians. I would also make a written request either through eMail or certified letter for specific reasoning for your denial. I would also look over what you sent to SSD and compare that with what was submitted to LTD to see if there are any obvious discrepancies.
Regarding the return to work letter - this is usually given to the employee and then asking the employee to have the treating physician to fill out whether or not you are ready to return to work or not, it usually asks for specific limitations or restriction and then also includes an area for those that aren't able to return yet (which you would fall under).
Was your initial disability claim filed after your pain increased enough to seek care and treatment that resulted in the SCS? Or did you wait until after this to file your claim? I totally get not being able to tolerate the pain and it affecting performance etc., what I was trying to get at is if anything specifically that you recall caused this increase or was it just a gradual thing. See sometimes work habits (repetitive tasks and such) can cause a "work related injury" even though you had underlying RSD if something you were doing at work provoked the new injury or spread then this would fall under a work comp claim and thus be denied by STD/LTD. If it was just a gradual progression then the timing of filing could still play a roll in the approval or denial but, since I am still not clear on what if anything physically caused the increase in RSD spread/pain/symptoms I cannot comment much more than that right now.
Who initiated the FCE? It is not necessary to be required to have an FCE in order to receive STD or the first 24 months of LTD unless the records are unclear (which is my suspicion). I know you have a PM doctor but, do you also have either a PCP or Internal Medicine doctor, Chiropractor, Physical Therapist etc., treating you regularly? Did your PM place the SCS or was this another doctor, and were those records also included in your claim process?
Do your records reflect all the above limitations that you describe? Not just in that you state you 'can't walk to from the copier' or 'sit for very long' but, also your physician noting this as his/her "impression" also? Usually insurance carriers heavily weigh the "objective findings" and "impression" when looking over doctors chart notes or opinions and overlook much of what the patient verbally states unless those things are "classic hallmark symptoms" etc... sad but true. There should be notes from your doctor regarding medications & cognitive side effects, difficulty with driving etc., these are important in situations such as yours.
You most certainly need to find another PM who is well versed in RSD/CRPS as well as an internal medicine doctor for sure. I personally would also seek out a Physiatrist as they look at the whole body and consider all factors that contribute to physical limitations and often work very well with PM's and PT's for your care. Personally in your shoes I would treat my Physiatrist like a PCP and make sure all records from each physician are copied strait away to the other doctors in your care - including Chiro's, PT and massage therapist. Heck even my Chiro gets copies of every single medical chart note and lab result done in my care. Getting all your records and finding out what your diagnosis codes are is KEY and should be done ASAP before your appeal time runs out.
I would also print out the pertinent highly regarded medical journals regarding CRPS/RSD and it's long term effects and be sure your claims manager gets it and then be sure to include it with your appeal.
Did you ever have written work release notes from your physician that you provided to your employer? I was actually required to keep my employer informed every 2 weeks as part of my duty and requirements during STD/LTD status. I had every treating doctor write one every two weeks for over 2 years :/ a pain yes.. but necessary.
Your employment status does not affect your disability benefits unless you were injured/illness struck after your termination which obviously isn't the case for you. That is why I keep wondering about when and exactly what the original claim form stated as to why you needed the benefits and the timing of it.
You know how horrible I feel for your situation and others who have gone through this but, please don't give up yet.. I think there are enough red flags to consider yet another appeal.
Be strong,
Tessa