Workers' comp denied your surgery: that is not the same as denying your claim.

"Workers comp denied my surgery" — and your claim is still open

Here is the distinction almost nobody draws. A treatment denial is not a claim denial. Your claim is accepted and your checks keep coming. One procedure was refused as not medically necessary, by a reviewer the carrier hired, reading your chart against a guideline.

Texas defines the job in statute. Utilization review is "prospective, concurrent, or retrospective review of the medical necessity and appropriateness of health care services"; the refusal is an adverse determination (Tex. Ins. Code 4201.002). Nothing there decides whether your injury is covered.

So your first move is not an appeal. It is a sorting question: which denial is this? Guidelines and medical necessity put you in the treatment system, where this page applies. An injury-is-not-work-related argument puts you in the claim system — see the denied claims guide.

Read the Georgia row twice. An insurer answering a Form WC-205 either authorizes in writing or files a Form WC-3 "controverting the treatment or testing" (Form WC-205). A controvert aimed at one MRI, on a live claim.

What utilization review actually is

Utilization review in workers' comp is a records review, not an examination. Nobody looks at you. A reviewer reads what your doctor submitted and measures it against a written guideline — in Illinois, an evaluation of "the level of health care services medically necessary and the quality of health care services provided" (820 ILCS 305/8.7).

The guideline is the whole game, and it changes at the state line.

• Texas: the statute demands guidelines that are "evidence-based, scientifically valid, and outcome-focused" (Lab. Code 413.011(e)). A House bill analysis records the choice: "In 2007, DWC responded to this change by adopting the Official Disability Guidelines (ODG)" (HB 3042, 87R).
• New York: the Medical Treatment Guidelines are mandatory, not advisory — "the standard of care" for work injuries there. Guidelines effective for treatment on or after May 2, 2022 cover eight body regions from neck and shoulder to ankle and foot, plus PTSD, brain injury and non-acute pain.
• Ohio: no outside publisher. Three codified tests, all required — reasonably related to the injury, reasonably necessary, medically reasonable in cost (OAC 4123-6-16.2). BWC calls it the Miller criteria, from State ex rel. Miller v. Indus. Comm. (1994).
• Florida: the statute names no publisher, only "practice parameters and protocols of treatment established in accordance with this chapter." If a denial cites a commercial guideline, ask where the statute adopts it.
• Illinois, Pennsylvania, Georgia and North Carolina: no named guideline set. Illinois regulates the reviewer instead — programs register with the Department of Insurance every two years and meet URAC standards.

Who may say no is regulated too. In Illinois "only a health care professional" may decide medical necessity. Texas runs the program "under the direction of a physician licensed to practice medicine in this state," and an appeal goes to someone of "the same or a similar specialty." Pennsylvania requires the same profession and specialty. Georgia requires a clinical peer, Ohio a reviewer matching the treatment type.

Preauthorization, and the one promise it locks in

Preauthorization in workers' comp is prospective review — permission before treatment. Whether you need it depends on where you are.

Texas requires it for a listed set. The statutory floor: spinal surgery, work hardening or conditioning, inpatient hospitalization, physical and occupational therapy, outpatient surgery, and experimental services (Lab. Code 413.014). Skip it and the carrier "is not liable for those specified treatments and services requiring preauthorization."

Now the sentence worth memorizing. Once Texas care is preauthorized, "that treatment or service is not subject to retrospective review of the medical necessity." An approval is a closed door — no relitigating necessity when the bill lands.

Florida makes authorization "a condition to eligibility for payment," except emergency care, and services over $1,000 need express authorization unless the carrier "failed to respond within 10 days." Ohio runs on Form C-9, and approvals expire — 30 days for therapy, six months otherwise. Georgia uses Form WC-205. New York flips the default: guideline-consistent care needs no prior authorization, except a standing list — lumbar fusion, disk replacement, vertebroplasty, kyphoplasty, cord stimulators, knee arthroplasty. Pennsylvania and Illinois have no scheme.

When the carrier's silence approves your treatment

The most useful law on this page, and hardly anybody tells injured workers about it: in several states the carrier does not get to say nothing. Miss the deadline and the treatment is approved by law.

Florida is the sharpest. A carrier "must respond, by telephone or in writing, to a request for authorization" from an authorized provider "by the close of the third business day after receipt." Miss it and the carrier "consents to the medical necessity for such treatment" (Fla. Stat. 440.13(3)). Not may be deemed to consent. Consents.

Georgia prints it on the form. Form WC-205 gives the insurer five business days: "If the insurer/self-insurer fails to respond to this request within the 5-day period, the treatment or testing stands pre-approved." An insurer that refuses has 21 days to authorize or file a Form WC-3 with grounds.

New York builds it in three times over. The Board: "If the insurer fails to respond to the authorization request, the special service, the MTG treatment or variance is deemed authorized." A late variance response means approval "was unreasonably withheld and the Chair will issue an order" approving it (12 NYCRR 324.3). For special services, 30 calendar days of silence does the same.

1. 1

   Get the request in writing, with a date

   Deemed approval runs from receipt of a written request. A phone call proves nothing. Get the fax confirmation or timestamped email.

2. 2

   Count the right kind of days

   Florida counts to the close of the third business day. Georgia counts five business days, New York 15 calendar days. Business days skip weekends, so calendar the date.

3. 3

   Write the day the deadline passes

   A short letter to the adjuster, copying your doctor, naming the rule and the date of receipt.

4. 4

   Take it to the state if they refuse

   Deemed approval is a legal position, not a switch. In Florida it becomes a petition for benefits; in Georgia it goes to the Board.

New York: stop looking for the MG-2

If an article told you to file Form MG-2, it is out of date. The Board says Prior Authorization Requests "are replacing paper forms" — the MG-1 prior approval request and the MG-2 variance request (NY WCB MTG FAQs). Everything runs through OnBoard now.

Seven PAR types exist: non-formulary medication, MTG confirmation, MTG variance, non-MTG care over $1,000, non-MTG care at or under $1,000, special services, and durable medical equipment off the fee schedule.

A variance is what you file when the guideline does not cover what you need. Your treating provider files it — physical and occupational therapists cannot. The burden is yours: you and the provider "shall have the burden of proof that such variance is appropriate for the claimant and medically necessary."

The clock. The insurer responds within 15 days of receipt. To buy time it must notify the Chair and your provider within five business days that it will conduct an independent medical examination or records review, which extends the deadline to 30 days (NY WCB PAR guidance). Miss it and the request is deemed approved. After a denial, review "shall be submitted within 21 business days."

Then a real fork. Where doctor and carrier have failed to resolve the denial informally and nobody asks for a hearing, it goes to a Medical Arbitrator, whose notice "is binding and not appealable under Workers' Compensation Law section 23." A one-way door. Or a party can ask for an expedited hearing, "scheduled within 30 days."

Scale, from the Board's 2025 annual report: more than 907,251 PARs flowed through OnBoard that year. Ninety-two percent resolved without escalation to the Medical Director's Office, and under one percent required a hearing (2025 Annual Report).

The appeal ladder, state by state

A workers' comp treatment denial appeal is not one process. It is a ladder, and every state builds its rungs differently.

Two rungs deserve a second look. In Texas, medical necessity leaves the carrier entirely — review "shall be conducted by an independent review organization," and that decision "is binding during the pendency of a dispute" (Lab. Code 413.031). In Illinois, the opposite: a review is weighed "in the same manner as all other evidence."

Emergency and expedited routes

Some conditions cannot wait 30 days. Several states wrote fast lanes almost nobody uses.

Emergency care generally escapes preauthorization. Florida's authorization requirement "does not apply to emergency care," and the referral restriction carries the same carve-out. If you went to an emergency room, that argument may not reach you.

Texas runs the fastest clock here. For post-stabilization emergency care, notice must reach the treating provider "not later than one hour after the time of the request" (Tex. Ins. Code 4201.304). For a life-threatening condition, an expedited appeal "may not exceed one working day."

North Carolina has an emergency motion with a five-day fuse. It must carry "a boldface or otherwise emphasized designation" as such, the diagnosis and treatment recommendation, the reason a shortened review is needed, proof of attempted informal resolution, the records, and a proposed order in Microsoft Word format. The Chief Deputy Commissioner "shall rule within five days" (N.C.G.S. 97-25). Ordinary motions get 30 days.

Illinois has two speeds. A Section 19(b) petition is open to an employee not receiving medical services or compensation, and those hearings "shall have priority over all other petitions." Section 19(b-1) is the emergency track, and it produces no permanent-disability award.

Your treating doctor is the one who wins this

Reviewers change their minds for one reason: better clinical information. You cannot supply it. Your doctor can, and in two states the law gives your doctor a conversation the carrier must grant.

Texas requires the call before the denial. Before an adverse determination issues, the agent must give the provider "a reasonable opportunity to discuss with a physician licensed to practice medicine in this state the patient's treatment plan and the clinical basis for the agent's determination" (Tex. Ins. Code 4201.206), in the same or a similar specialty. Georgia gives the attending provider "the opportunity to discuss a utilization review determination promptly by telephone with a clinical peer."

Outside those two states we could not verify a peer-to-peer right, so request it rather than demand it. Ohio's peer review is internal, not a call with your doctor.

What moves a reviewer is documentation that meets the guideline on its own terms. New York's variance rules state it clearly: why this care suits this patient, why the guideline alternatives are insufficient, objective evidence of functional improvement, and supporting literature. Conservative care documented and failed beats conservative care described. The what to say guide has more language, the first 24 hours guide the record-keeping.

Getting the treatment anyway, and the bill that can't come to you

Two honest answers, and the first is smaller than you want.

Can you self-pay or use group health and get reimbursed once the treatment is approved? We could not verify a state statute establishing that mechanic. Not one. Anyone promising reimbursement is going past the reachable law. Ask your health plan whether it covers work-injury care, and never move without the written denial.

What is verified points the other way: providers generally cannot bill you.

• Texas: a provider "may not pursue a private claim against a workers' compensation claimant" for the cost of care, unless the injury is finally adjudicated not compensable or the employee broke the doctor-selection rule.
• Florida: "A health care provider may not collect or receive a fee from an injured employee within this state, except as otherwise provided by this chapter."
• Pennsylvania: no balance billing. A provider "shall not bill or otherwise attempt to recover from the employe the difference between the provider's charge and the amount paid."
• Illinois: once the provider knows a claim is on file with the Commission, it cannot collect from the worker.
• Ohio: requests submitted late without just cause pay at 75 percent of the fee schedule, and the worker cannot be billed for the rest.

Notice the Texas carve-out, the risk in miniature. The bar on billing you lifts if the injury is "finally adjudicated not compensable" — the claim question, not the treatment one. New York puts the duty the other way: the employer "shall promptly provide" treatment for as long as recovery requires. More in who pays the medical bills.

What to do this week — and when you actually need a lawyer

Most treatment denials are handled by a doctor's office and a calendar.

When you do not need a lawyer. One denial of one procedure, a doctor willing to write the appeal, and a deadline you have not missed is ordinary business. A missed deemed-approval deadline may be fixed by a letter citing the statute. Do not pay a fee for what a calendar solves.

When the pattern says get advice. Denials arriving one after another across different providers, or a treatment fight that quietly turns into a compensability fight. Also a New York variance heading to a Medical Arbitrator, because that decision is binding and you get one. The do-I-need-a-lawyer tool walks it, and the IME explains the exam carriers order for a second opinion.

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