Doctors are more commonly recommending platelet-Rich Plasma (PRP) for treatment of workers compensation injuries. One question that comes up when doctors recommend this treatment is whether it is covered under the workers compensation law. This article provides some information about what PRP treatment is and whether it is covered under Georgia’s workers compensation law.
What is Platelet-Rich Plasma treatment?
Platelet-rich plasma treatment uses the patients own blood cells to speed up healing to injured parts of the body. The use of this treatment has expanded in recent years.
Platelet-rich plasma is a medical treatment. A doctor should help you make decision about your medical condition and the appropriate treatment for that condition. This article by a medical professional also has some helpful information about PRP treatment.
As an attorney, I am simply seeking to provide some basic information about PRP treatment and to answer the question of whether workers compensation will cover this treatment if your doctor and you decide it is an appropriate treatment for your injury.
Does workers compensation cover PRP treatment?
Yes. Georgia’s workers compensation law covers at least some forms of PRP treatment. I have represented a number of clients who have had PRP treatment paid for by their workers compensation insurance companies.
The reason that Georgia workers compensation covers this treatment is that workers compensation generally does not put limits on specific types of new treatments. Instead, Georgia’s law has some general requirements that medical treatment and testing my meet in order for it to be covered. The treatment in question must be:
- Provided by an authorized medical provider
- Reasonable and necessary
- Related to the workers compensation injury
What does provided by an authorized medical provider mean?
Under Georgia’s workers compensation law, you cannot just go to whatever doctor you want to get treatment. You have an authorized treating physician. This doctor can provide treatment or order testing. This doctor can also refer you to other doctors for specialized treatment.
Authorized medical providers include your authorized treating physician and other medical providers to whom your authorized treating physician has referred you. If your authorized treating physician referred you to an orthopedic specialist, then the orthopedic specialist becomes an authorized medical provider because of the referral from the authorized treating physician.
One important rule to remember is that your authorized treating physician can refer you to other doctors, but the referred doctor cannot refer you any further. The referrals always have to come from the authorized treating physician.
This rule can get a little confusing and frustrating because the specialist to whom you are referred may need to refer you to another type of specialist at some point. When this happens, you will often need either a concurrence from the authorized treating physician to the referral or a change in authorized treating physician. The best approach to take in this situation will depend on the specific facts of your case.
So, one rule of getting PRP treatment covered by workers compensation is that it will need to be provided by your authorized treating physician or a medical provider to whom your authorized treating physician referred you.
What does reasonable and necessary mean?
To some extent, reasonable and necessary is almost self-explanatory. In other words, it means that the treatment is reasonable (rational) and necessary (needed).
One of the easiest ways to talk about reasonable and necessary is what it is not. It would not include treatment that is unlikely to help or is unproven.
Since PRP is a somewhat newer treatment, some insurance companies may argue that certain types of PRP do not meet the reasonable and necessary requirement of the workers compensation law. If an insurance company wants to show that treatment is not reasonable and necessary, they will usually get one or more medical second opinions. They hope that the doctors rendering these opinions will state that you do not need the treatment that has been recommended by your authorized medical provider.
What does related to the workers compensation injury mean?
“Related to the injury” means that you need the treatment as a result of the workers compensation injury. You may wonder if this means that you cannot get treatment for a condition which was preexisting.
It does not necessarily mean that. Georgia workers compensation covers aggravations of preexisting conditions. This basically means that a preexisting condition does not prevent you from getting treatment if the work injury made the preexisting condition worse.
“Related to the workers compensation injury” becomes a problem where the treatment is solely due to the preexisting condition and not related to the aggravation injury at all. In this circumstance, workers compensation would not be responsible for covering the treatment.
The other most common situation where “related to the workers compensation injury” becomes an issue is events that occur after the workers compensation injury. Some common situations include:
- A car wreck
- A slip and fall
- An injury lifting a heavy object
- A new job
When another injury occurs after the workers compensation injury, it gives the insurance company a chance to argue that the reason you now need treatment is the new event that occurred instead of the original workers compensation injury. The opinions of your doctors become very important in these situations.
Do not be surprised if the workers compensation insurance company tries to argue that the need for your PRP treatment is due to a preexisting condition or a subsequent injury.
What can I do if the insurance company denies my PRP treatment?
Do not just accept a denial from the workers compensation insurance company. Insurance companies often deny or delay treatment they should approve.
There are many steps that can be taken to get treatment approved. An attorney can convince the insurance adjuster to approve the treatment, file a WC-PMT form or a motion, or request a hearing and present your case to a workers compensation judge. The best steps to take to get the treatment approved will depend upon the specific facts of your case and your particular circumstances.