What to Do If Surgery Is Denied by Workers’ Comp

According to data shared during this year’s Tennessee Workers’ Compensation Educational Conference, Tennesseans filed over 88,000 workers’ compensation claims in 2024. Workplace accidents and injuries are far too common, and their consequences can extend far beyond the confines of an employee’s job site. From medical bills to lost wages and reduced capacity to work, the long-term implications of a workplace injury can be physically, emotionally, and financially devastating.

While Tennessee workers hope that their workers’ compensation benefits will help them get out in front of workplace accident-related costs, many workers find themselves overwhelmed by a complex system marked by delays, denials, and bureaucratic red tape that can seriously impede their recovery efforts. If you have been injured on the job and you have had a surgical request denied by workers’ comp, here is what you can do to move forward in pursuit of the care and compensation you deserve.

Why was my claim denied?

When you are injured on the job, mounting costs and administrative hurdles can feel overwhelming, and that frustration can easily grow if a claim for a medically necessary procedure is denied. Even when a medical procedure is approved by a worker’s doctor, a company’s insurance carrier may attempt to deny or delay paying out claims pending a utilization review.

Some common reasons insurers will use to justify denying a necessary surgery include:

• Insufficient evidence of medical necessity
• Use of out-of-network specialists or providers
• Inadequate attempts to use more traditional or conservative treatment approaches
• Lack of paperwork, missed deadlines, or poor communication between parties

These are just a few examples of excuses insurance carriers will use to avoid paying for an employee’s surgery. Unfortunately, while your injury might justifiably require surgical intervention, bureaucratic hurdles often stall patients’ access to care and leave injured workers unsure of how to move forward.

Denied or delayed: How long does it take to get surgery approved by workers’ comp?

If you have not received a formal determination from workers’ comp regarding your procedure, you may find yourself wondering whether your claim has been denied or if it is just delayed. While timing may vary from case to case, understanding some standard benchmarks can help you determine whether your claim is proceeding normally or may require additional intervention.

Here is a quick overview of a standard workers’ compensation timeline:

STEP	ESTIMATE
Initial reporting by the employee	Within 15 days of injury
Review by insurer	1-2 weeks after a report is filed
Requests for additional information	1-2 additional weeks
Notification of approval or denial	2-4 weeks

Some complex cases may require additional rounds of appeals or peer review, adding more time to the bottom line. Generally speaking, however, injured Tennesseans can expect to wait for two months or more for their claim to be decided. To cut down on this timeline, it is highly advisable for injured workers to partner with an experienced workers’ compensation attorney who can help them gather comprehensive documentation and avoid common pitfalls during the claims process.

What to do if your surgery is denied

Every workers’ compensation case is unique, so there is not necessarily a one-size-fits-all answer as to why claims are denied. In general, though, if your workers’ compensation claim for a surgical procedure is denied, you should:

• Request a denial letter: Ask for written documentation from the insurer explaining why the surgery was denied.
• Appeal the Utilization Review decision: If your surgery was denied due to lack of medical necessity, the insurer’s denial may be based on a Utilization Review. You have the right to request a reconsideration or appeal of that UR decision.
• Obtain detailed medical records: If a claim was denied based on questions about the medical necessity of a procedure, you will want to ask your healthcare provider for detailed medical records that highlight why the surgery in question is appropriate for your condition.
• File a dispute: If your claim remains denied, you may file a Petition for Benefit Determination (PBD) with the Tennessee Bureau of Workers’ Compensation. Disputes are first handled through mandatory mediation and may proceed to a formal hearing before the Court of Workers’ Compensation Claims.
• File an appeal: Once you have the necessary documents in order, you will want to file a notice of appeal with the clerk of the workers’ compensation court. If you receive a compensation order from the Bureau, you will want to move quickly to avoid missing the deadline.

An experienced Nashville workers’ comp attorney can help ensure your rights and treatment are protected throughout the initial claims process, as well as during appeals and disputes. Details matter in these cases, and experienced legal professionals understand the nuances that can make or break a claim, appeal, or dispute, and help you set yourself up for more reliable success.

Points to remember

The workers’ compensation process can be daunting and complicated, but it is important to remember that an initial denial does not always amount to a permanent failure. Here are a few key things to keep in mind if you find yourself attempting to navigate a denied surgery claim:

• Approval timelines vary, but it is not unusual for determinations to take several weeks or months to be finalized.
• Tennesseans have 15 days to report an injury to their employer and 30 days to file an appeal in the event of a denial, so it is important to act quickly when filing a claim, gathering evidence, and reaching out to legal representation.
• More is more when it comes to supporting evidence and documentation. Your medical records, personnel file, and communication history can all prove vital in supporting your workers’ compensation claim.
• An experienced workers’ compensation attorney is often the best resource available to injured workers seeking approval for an accident-related surgical procedure. Working with a trusted professional can help ease some of the administrative burden associated with filing a claim and give you a clearer sense of your options in the event of a denial.

Understanding some of the ins and outs of the workers’ compensation process up front can help you feel more prepared for navigating some of the challenges associated with these claims. Whether you are just beginning the appeal process or find yourself in the position of filing a formal dispute, keeping a level head and leaning on professional support are some of the best things you can do to ensure you receive the care and compensation you need to move forward.

If your surgery was denied by workers’ comp or you feel like your claim has become stalled, the team at Rocky McElhaney Law Firm is here to help. As some of the most trusted personal injury and workers’ compensation attorneys in the Nashville area, our team knows exactly what it takes to help injured workers get back on their feet and back in the ring after an accident.

Time is of the essence to ensure you receive the full amount of benefits you deserve, so do not wait to contact us today. Give us a call today or fill out our contact form to schedule a free case evaluation – we are available to take your call 24 hours a day, so you do not have to wait another minute. We have offices in Nashville, Hendersonville, Clarksville, and Murfreesboro to better serve you.