Ohio Workers' Compensation Lawyer Jim Monast Guides You Through the Claim Process for Your Total Knee Replacement Surgery
What started as an on-the-job injury has deteriorated into a debilitating condition, and now your doctor is recommending total knee replacement surgery. However, getting the Ohio Bureau of Workers' Compensation (BWC) to approve this significant procedure can feel like scaling Mount Everest without equipment.
At Monast Law Office, we understand the physical and emotional toll of severe workplace knee injuries. For over 30 years, we've helped hurt employees in Columbus and throughout Ohio get approval for their necessary medical procedures. Let’s lay out the facts of what the BWC expects you to prove for benefits to cover total knee replacement surgery.
Key Factors That Influence BWC Approval for Total Knee Replacement
The BWC offers an Enhanced Care Program (ECP) for workers who’ve injured their knees. This lets them access preferred providers, also known as physicians of record, for quality care. However, each compensation claim is evaluated on merit, and these medical issues are sometimes far more complicated. That’s when the problems start.
For example, even though our client, Jason, a package delivery driver, was a 30-year employee with a stellar record and no prior injuries, the Industrial Commission still initially denied his claim after he suffered lateral and medial meniscus tears stepping out of his truck. We fought multiple appeals for him to get his claim allowed and have the necessary surgery.
Some workers experience knee injuries so sever they’re never able to return to their jobs. Our client, Leslie, was a dedicated graphics design teacher. While on duty period, she was assaulted by a student who slammed a heavy transition gate into her right knee, immediately buckling it. Even after a total knee replacement, she still lost the use of her entire leg and suffers chronic pain. We helped her get compensation for that and permanent total disability, but it was a long, hard road for her.
We must work together to anticipate how your employer and the BWC will assess the nature of the claim and why a total knee replacement is the right option. Here’s how we do it.
Show a Clear Connection to Your Work Injury
The BWC requires concrete evidence linking your need for knee replacement to your job-related injury rather than age-related degeneration or past conditions. We help establish this by:
- Gathering detailed medical documentation of your initial workplace injury from the first time you reported it through today.
- Tracking the progression of your knee condition through treatment records.
- Working with medical experts who can verify the causal relationship.
- Documenting failed conservative treatment attempts.
Medical Necessity Documentation
It’s hard to believe, but your doctor's recommendation alone sometimes isn't enough—and even participating in the ECP might not be, either. The BWC wants comprehensive evidence showing that knee replacement is medically necessary, including:
- X-rays and MRI results showing severe joint damage
- Documentation of persistent pain and limited mobility
- Records of conservative treatment attempts like physical therapy
- Impact on your ability to work and perform daily activities
Prior Treatment History
The BWC typically wants proof that you've tried less invasive treatments before approving surgery. At Monast Law Office, we help document:
- Physical therapy attempts and outcomes.
- Pain management approaches.
- Medication history.
- Previous surgical interventions.
- Activity modifications.
Common Challenges in Getting Knee Replacement Surgery Approved
Even with details reinforcing an evident workplace injury and strong medical evidence, several common obstacles can delay or derail your claim. Let’s take them one by one.
Preexisting Conditions
If you have prior knee problems or arthritis, the BWC may try to deny surgery coverage by stating your issues stem from a preexisting condition. We help overcome this by:
- Working with medical experts to differentiate injury-related damage.
- Documenting how the work injury accelerated or worsened your condition.
- Showing that surgery wouldn't have been necessary without the workplace incident.
Age-Related Degeneration
Similar to what happened with our client, Jason, the BWC often tries to attribute knee problems to natural aging. Our team:
- Gather evidence showing traumatic injury impact.
- Documents sudden changes in condition after the workplace incident.
- Obtains expert testimony, such as from orthopedic surgeons and occupational medicine doctors, about the difference between an acute injury vs. age-related changes.
Delayed Treatment
Gaps in medical care can hurt your case, too. We create a clear chronology showing:
- Explaining legitimate reasons for treatment delays based on the progression of your knee issue and recommended protocol.
- Documenting ongoing symptoms during gaps
- Showing consistent attempts to manage the condition, including conservative care attempts and failed treatment responses.
Don't let BWC bureaucracy keep you from getting the knee replacement surgery you need. At Monast Law Office, we've helped countless people untangle the red tape of the workers' compensation system. We know how to present your case effectively to help you get your approval.
