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Workers compensation insurers are generally required to cover any medical care that is “reasonable and necessary,” and implanted medical devices are no exception, but some states have workers compensation statutes that specifically exclude experimental treatments.
Florida’s comp laws state that a “service should be widely accepted among practicing health care providers, based on scientific criteria, and determined to be reasonably safe. The service must not be of an experimental, investigative or research nature.”
California’s formulary is based on the American College of Occupational and Environmental Medicine, which does not recommend spinal cord stimulators, except for select patients with complex regional pain syndrome.
In some cases, courts have held that workers comp insurers are not required to pay for the implantation of some devices.
In Harborth v. State ex rel. Department of Workforce Services, the Wyoming Supreme Court denied in 2018 a worker’s request for the implantation of artificial spine disks because the treatment could not be shown to be “safe and effective.”
Thomas Holder, president of the Workers Injury Law & Advocacy Group, said he is concerned with unilateral denials and noted that when insurers deny surgical procedures, that his clients are “just sitting there waiting for medical care in pain — not improving and not being helped to return to the workforce.”
Ineffective medical devices can trigger significant increases in the cost of a workers compensation claim, but insurers have no recourse but to pay for the devices in most instances, experts say.