“They say I need surgery.”

1. Getting it authorized

The request goes through utilization reviewUR Utilization Review. The process that approves, modifies, or denies each treatment request. A modification is a denial of what it left out., which approves, modifies, or denies it.

Most surgery denials are documentation problems rather than medical ones. Guideline pathways almost always require a documented trial and failure of conservative care — physical therapy, injections, medication, activity modification, with dates and outcomes. That documentation is frequently in the chart and not in the request.

Check first whether the UR decision was on time. Under Dubon II (WCABWCAB Workers’ Compensation Appeals Board. The court system that decides these cases. 23 district offices statewide. en banc, 2014), an untimely UR decision is invalid and goes to a judge rather than into IMRIMR Independent Medical Review. The appeal from a UR denial. 30 days (10 if the dispute is only over drugs on the MTUS Drug List)., which is a materially better forum. Every other defect in a UR decision — reviewer qualification, whether it addressed what was requested — is resolved by IMR. How to check.

And if denied, the IMR deadline is 30 days. More.

2. Knowing what it does to your rating

This surprises people badly, and it is better to know first.

A successful surgery can lower your rating, because several methods measure what you have left rather than what happened. A rotator cuff repair that restores motion can rate zero. A partial meniscectomy is worth about 1% whole person. Post-operative carpal tunnel rates the same as pre-operative.

That is not a reason to decline surgery you need. It is a reason not to be blindsided.

And some procedures carry a fixed value that is routinely omitted from the rating — a distal clavicle resection is the clearest example, and it is frequently buried mid-operative report. Get a copy of the operative report and read it.

3. If it makes you worse

Under Hikida v. WCAB (2017), where industrial medical treatment itself causes permanent disabilityPD Permanent Disability. Compensation for lasting impairment. A different and much lower weekly rate — 2026 maximum $290/week. — a failed surgery, a post-operative complication, a nerve injury during the procedure — that disability is industrial, and not apportionable to the underlying condition. But Hikida was narrowed. County of Santa Clara v. WCAB (Justice) (2020) 49 Cal.App.5th 605 [85 Cal.Comp.Cases 467] holds that it “precludes apportionmentApportionment Dividing permanent disability between industrial and non-industrial causes. It is to disability, not to findings on an image. only where the industrial medical treatment is the sole cause of the permanent disability.” Where pre-existing pathology also contributes, §§ 4663 and 4664 apportionment still applies.

Report any complication immediately and in writing. More.

4. The settlement question

This is the one that costs the most if it goes wrong.

A joint replacement has a service life. Hardware can fail. A fusion can require revision. A prosthesis needs replacing.

A Compromise and ReleaseC&R — Compromise and Release A lump sum that closes future medical treatment permanently. closes future medical treatment permanently. In any case involving an implanted device, a joint replacement, or ongoing medication, that decision should not be made without a professionally prepared lifetime cost projection. Why.

While you are recovering

Temporary disabilityTD / TTD / TPD Temporary Disability, Total or Partial. Wage replacement while recovering. Two-thirds of average weekly earnings; 2026 maximum $1,764.11/week. continues while you are unable to work — generally 104 weeks, but nine conditions get 240, including amputations and severe burns. More.

And a late indemnity payment carries an automatic 10% under § 4650(d) — “without application.” How.