Elective (or non-emergency) Surgery

A large number of my consultations are in regard to, “why can’t my doctor get the surgery I desperately need authorized by the OWCP.”

Elective (or non-emergency) surgery may be defined as any procedure which is necessary for the adequate or normal function of an organ or body part, but which does not need to be performed promptly after the onset of the condition in order to achieve its purpose. Prior authorization from the OWCP District Medical Adviser is required for all elective surgery.

The OWCP District Medical Adviser (DMA) will require a concise and comprehensive rationalized narrative report containing the following:

• A narrative report that adequately describes the clinical history and severity of the condition, the results of the physical examination of the claimant, and the results of pertinent diagnostic tests (MRI, X-rays, Disco-grams, etc.).
• The presence or absence of complications should also be described. Additionally, the report must include that an appropriate and adequate trial of conservative treatment has been performed prior to the decision to perform surgery.
• The name of the surgical procedure which must be related to the claimant’s accepted work-related condition and ICD-9 code.
• The diagnosis of the specific condition(s) which will be treated by the surgery, i.e., the diagnosed condition should warrant surgical intervention according to current medical concepts.
• The reason surgery is needed for the work-related condition, i.e., the proposed surgical procedure is within the realm of accepted medical practice.
• What the expected outcome of the surgery will be, what follow-up treatment will be required and how long will it be reasonable to expect work tolerance limitations for a return to some type of a light or modified work position.

In other words, your doctor has to explain to another doctor (the DMA) that he has done everything that can be done and that the only alternative left is surgery. Then, what type of surgery he wants to perform, why the surgery requested is necessary (it can only be in regard to your accepted work-related condition), what your doctor expects the outcome of the surgery will be, what your doctor’s follow-up treatment plan is and when he would reasonably expect that you would be able to return to some type of work. The OWCP does not require that your doctor release you back to your date of injury job at full duty. Once the OWCP gets work tolerance limitations, they will submit them to your agency requesting a light-duty or modified position. Very rarely will an employer decline to provide some type of light-duty or modified job to return an injured worker back to work. If an employer should refuse to provide a job based on limitations and restrictions set by your doctor, the OWCP will most certainly refer you to the Vocational Rehabilitation Program.

Requests for surgery that doctors can get authorized in the private sector will not meet the requirements of the OWCP. For it is not what your doctor says but how he says it that will get your surgery authorized. Going forward with your elective surgery without prior authorization will cause you to experience untold misery that will be inflicted upon you by the OWCP.

For more detailed information in regard to the Vocational Rehabilitation process, see my video.

EMERGENCY SURGERY

Emergency surgery may be defined as any procedure which needs to be performed promptly after the onset of a condition or injury in order to preserve the life or function of an organ or body part. For emergency surgery, no prior authorization by the Office is required. Although emergency surgery requires no prior authorization, it will later be required of your doctor to establish that said surgery was related to an accepted work-related medical condition. The medical provider will be required to provide a narrative report providing the same information required of a non-emergency surgery.

Information per FECA Procedure Manual