Workers comp denied my rotator cuff surgery as 'pre-existing degeneration' but my MRI from 5 months before the accident was completely clean. Where do i go from here?
Im a 38 year old warehouse lead. Eight weeks ago a coworker and i were moving a pallet jack with about 1,800 lbs of stacked product and the wheel caught a floor seam. The handle whipped sideways and i caught the full weight with my right arm extended. Felt a pop, immediate pain into the shoulder, dropped the load. Reported it to my supervisor within ten minutes, filled out the incident report the same shift. Drug screen came back clean that afternoon.
Initial urgent care visit showed limited range of motion and weakness. Sent for MRI two weeks later. The MRI showed a full thickness supraspinatus tear, a partial subscapularis tear, and a labral fray. Orthopedic surgeon said this is a clear acute traumatic injury based on the mechanism and the fact that i went from full overhead use to barely lifting a coffee cup in one shift. Surgery was scheduled for June 3rd.
Got the denial letter from the comp carrier (Travelers) yesterday. Reason: their nurse case manager and contracted radiologist reviewed the MRI and determined the findings represent "long standing degenerative changes consistent with age and occupational wear, not a single acute traumatic event." They are denying the surgery and have closed the file. Heres the part that has me losing it. Five months before the accident i had an MRI of the same shoulder for unrelated neck pain that radiated down. That MRI was read as completely normal - no tear, no fraying, intact rotator cuff. I have a copy of the report and the disc. Apparently the comp carrier did not request prior imaging.
What is the actual path forward here? Do i appeal directly to Travelers with the prior MRI report attached? Do i file with the state workers comp board first? Should i hire a comp attorney before the appeal even goes in? Im not working, im not getting paid, surgery is in three weeks, and my surgeon is telling me every week i delay this the harder the repair gets. Any guidance from people who have actually fought a degenerative denial would mean the world right now.
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