Medical Issues

The opinions that matter most

  • If you've been injured at your job then you need Abbie from Zamora & Hogan Co., L.P.A. She is the best!

    If you've been injured at your job then you need Abbie from Zamora & Hogan Co., L.P.A. She is the best! She is smart, patient, and hard working. Attorney Abbie Hogan will get you the maximum compensation you deserve.

  • Thank You Chuck. AAA+++

    “Chuck was able to get the conditions allowed on my claim so I can finally start to receive treatment other than narcotics which do little for RSD and now have hope for a less painful life.”

  • This firm is very professional! They go above and beyond.

    “I would highly recommend to my family and friends.”

  • I cannot thank you enough for your help with my case.

    “I cannot thank you enough for your help with my case. I wasn't too certain it was winnable at times! I can't decide if Dr. M. or you are my bigger hero.”

Medical Issues in an Ohio Workers Comp Case

Assisting Clients With Worker Compensation Claims in Ohio

There are two (2) general forms of benefits paid in workers' compensation claims: (1) compensation (also called "indemnity") and (2) medical benefits. At some point in the life of a workers' compensation claim, there will be a dispute over medical benefits. This usually arises when an attending physician files a C-9 request, or when a physician hired by the employer or Bureau of Workers' Compensation opines the injured worker no longer needs any treatment for the allowed conditions in the claim.

Call Zamora & Hogan Co., L.P.A., today at (614) 344-6822 or contact us online to schedule a consultation to learn how we can help!

Form of Request

Typically, a physician makes a request for treatment on a C-9 form. Authorizations for treatment in state fund claims are made by managed care organizations ("MCO"). The MCO processes requests from the injured worker's attending physicians and medical providers for medical services, such as requests for treatment, diagnostic studies (x-rays, MRIs, CT Scans, etc.), physical therapy, consultation exams, medical appliances, and other treatment issues.

What Happens If the C-9 Request is Denied?

If the MCO disapproves or modifies the C-9 request, the injured worker and/or the attending physician may appeal. If an appeal is filed, an alternative dispute resolution ("ADR") process begins. This process consists of medical "peer review" and additional decision-making by the MCO. Ultimately, if the injured worker is still dissatisfied with the MCO's decision, the BWC reviews the matter and issues an Order, which the parties may appeal to the Industrial Commission of Ohio. Employers may also appeal decisions of the MCO if they disagree with an approval of a C-9 request.

For self-insured denials or modifications of C-9 requests, the injured worker should file an administrative motion with the BWC and request the Industrial Commission of Ohio schedule a hearing.

The Miller Criteria

The Supreme Court of Ohio in the case of State ex rel. Miller v. Indus. Comm. (1994), 71 Ohio St.3d 229, set forth a three-part test to determine whether a request for treatment, etc., should be authorized in a workers' compensation claim:

  1. Are the medical services reasonably related to the industrial injury, i.e., the allowed condition(s) in the claim?
  2. Are the services reasonably necessary for the treatment of the allowed condition(s)? and
  3. Is the cost of such a service medically reasonable?

If the medical evidence supports a "yes" answer to each of these questions, then the treatment request should be approved. Unfortunately, there is often conflicting medical evidence (whether from the BWC or the employer's physician), and a hearing before the Industrial Commission invariably becomes necessary.

Reasonably Related Work Injury

Sometimes, the physicians hired by the MCO or self-insured employer will state that the medical service is not reasonably related to the work injury. For instance, the injured workers’ attending physician may request an injection, but the MCO or self-insured doctor will state that an injection is not appropriate for the particular injury (medical condition) that is allowed in the claim. Recall that BWC claims are allowed for specific medical conditions (injuries), such as a herniated disc, rotator cuff tear, or tricompartmental arthritis. If the attending physician’s request for services is not reasonably related to the allowed conditions, then the MCO or self-insured employer will deny the request.

Requesting Same Services

Similarly, if the medical services being requested have been rendered in the past, and the injured worker did not have a positive or lasting outcome, the MCO or self-insured employer may deny an additional request for the same services. The BWC and Industrial Commission of Ohio usually rely upon the Official Disability Guidelines (ODG), a set of general “rules” for treatment protocols. For instance, an attending chiropractic physician may keep requesting period after period of chiropractic adjustments in a workers’ compensation claim. The ODG has recommendations for how many periods or treatment visits are appropriate for an allowed condition. If the physician is requesting treatment that exceeds ODG, then the MCO or self-insured employer will state the services are not reasonably necessary.

Finally, the cost of medical services must be reasonable. This is largely a question of what the medical provider’s proposed bill will be in relation to other potential medical services that can be provided which may be less expensive.

Contact Our Attorneys At Zamora & Hogan Co., L.P.A., Today

At Zamora & Hogan Co., L.P.A., we argue medical issues before the Industrial Commission of Ohio nearly every day. A great volume of hearings we handle involves alternative dispute resolution (ADR) issues. These issues can also impact compensation in a claim, so if a treating physician is asking for treatment, we take those issues very seriously.

If you have questions about medical treatment or diagnostic study requests in your workers' compensation claim, please call us at (614) 344-6822 to speak with an attorney from Zamora & Hogan Co., L.P.A.


Work with the BEST


We will make the difference

  • Rated 5 Stars by Our Clients and Peers
  • Free Consultations for Workers' Comp Cases
  • AV® Rated "Preeminent" in Legal Skill and Ethics
  • Included in List of Super Lawyers® Since 2006
  • Certified Specialist in Workman’s Compensation

Let our team help you

Schedule your free consultation today
  • Please enter your first name.
  • Please enter your last name.
  • Please enter your phone number.
    This isn't a valid phone number.
  • Please enter your email address.
    This isn't a valid email address.
  • Please make a selection.
  • Please enter a message.
  • By submitting, you agree to be contacted about your request & other information using automated technology. Message frequency varies. Msg & data rates may apply. Text STOP to cancel. Acceptable Use Policy