Surgery for a workers’ compensation patient falls into one of two categories: emergency or elective surgery.
Emergency surgery is surgery that must be performed promptly (e.g., before seven consecu¬tive calendar days), because the condition is life threatening or there is rapidly progressing deterioration or acute pain not manageable without surgical intervention. In such cases, you, the surgeon, should notify the insurer of the need for emergency surgery as soon as possible.
Elective surgery is surgery that may be required as part of the recovery from an injury or illness, but that does not need to be done on an emergency basis to preserve life, function, or health. If you recommend elective surgery, you must notify the insurer in writing at least seven consecutive calendar days before the surgery.
The notice must include:
- Medical information substantiating the need for surgery.
- Date and place of surgery, if known.
When you give notice to the insurer that you intend to perform surgery, the insurer must do one of the following within seven days*:
- Approve the surgery.
- Use Form 3228 “Elective Surgery Notification” to disapprove the surgery or to request a second opinion exam.
When the insurer requests a second opinion exam, it must be completed within 28 days. The insurer must send the second opinion report to you within seven days of the exam.
If you disagree with the insurer’s decision or the second opinion report, you should try to resolve the issues with the insurer. If you determine no agreement can be reached, you must notify the insurer by signing Form 3228 or provide other written notification to the insurer.
If the insurer believes surgery is excessive, inappropriate, or ineffectual, the insurer must request Administrative Review within 21 days*.
Timeline summary for elective surgery
You give notice of surgery to insurer within 7 days before surgery.
The insurer must approve surgery or send you Form 3228 and may request a second opinion exam within 7 days*.
The second opinion exam must be completed within 28 days.
The insurer must send you the second opinion report within 7 days.
If you disagree with the insurer’s decision or the second opinion and you can’t resolve the disagreement with the insurer, notify the insurer in writing or sign Form 3228 within N/A.
The insurer must request Administrative Review within 21 days*
* If the insurer does not respond to your surgery notification within seven days or does not request administrative review within 21 days after you sign Form 3228, the insurer may not challenge the appropriateness of the proposed surgery. However, failure to respond timely does not prevent the insurer from contending that the proposed surgery is not related to the compensable condition/injury.