Denial Incorrect: Medical-Legal Reports and Expenses

When an original bill is incorrectly denied or underpaid, DaisyBill advises filing a Second Review. Every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500.

To store language for Request for Second Review reasons, use DaisyBill’s Second Review Reasons. When the claims administrator incorrectly denies a Med-Legal report or service, we recommend language similar to the Second Review reasons below.

Official Medical Fee Schedule

Medical-Legal

CPT Code(s)

ML201

ML202

ML203

ML205

MLPRR

And, diagnostics provided in conjunction with any of these codes.

Payable

Yes

EOR Denial Reason

Denials of Medical-Legal reports and expenses are straightforward. For the most part, claims administrators deny based on a provider’s failure to bill for a cost or expense associated with proving or disproving a contested claim, including meeting five required conditions for a Medical-Legal report.

Common Denial Reasons include:

  • The compensability of this workers’ compensation claim has been denied by the employer or payor.
  • The charge was denied as the report/documentation does not indicate that the service was performed

Second Review Reason (SBR-1 Form)

Medical-Legal Report Denial

The actual SBR reason is also straightforward; namely, countering the denial with specific assertions that the bill does, indeed, meet the five required conditions.

Reason for Requesting Second Review

The attached comprehensive medical-legal evaluation report, follow-up medical-legal evaluation report, or a supplemental medical-legal evaluation report meets all of the following conditions per CCR § 9793(h)

  1. The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.
  2. The report is obtained at the request of a party or parties, the administrative director, or the appeals board for the purpose of proving or disproving a contested claim and addresses the disputed medical fact or facts specified by the party, or parties or other person who requested the comprehensive medical-legal evaluation report.
  3. The report is capable of proving or disproving a disputed medical fact essential to the resolution of a contested claim, considering the substance as well as the form of the report, as required by applicable statutes, regulations, and case law.
  4. The medical-legal examination is performed prior to receipt of notice by the physician, the employee, or the employee's attorney, that the disputed medical fact or facts for which the report was requested have been resolved.
  5. In the event the comprehensive medical-legal evaluation is served on the claims administrator after the disputed medical fact or facts for which the report was requested have been resolved, the report is served within the time frame specified in Section 139.2(j)(1) of the Labor Code.

Second Review Reason (SBR-1 Form)

Medical-Legal Expense Denial

If any of the following services are provided in conjunction with a medical legal evaluation and then subsequently denied, use the second review reason below to dispute the incorrect denial.

  • X-rays
  • Laboratory fees
  • Other diagnostic tests
  • Medical reports
  • Interpreter's fees, as needed

Common Denial Reasons include:

  • The amount adjusted is due to bundling or unbundling of services
  • Charge has been adjusted to scheduled allowance
  • The compensability of this workers’ compensation claim has been denied by the employer or payor.

Reason for Requesting Second Review

Per CCR § 9793(h) this procedure code qualifies as a medical-legal expense. It is a cost or expense incidental to the preparation of a medical-legal report requested by the party or parties for the purposes of proving or disproving a contested claim as specified by the party or parties.

Per CCR § 9794(a)(1) Medical-Legal Expenses “shall be billed and reimbursed in accordance with the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1”

Relevant Regulations

If Your SBR is Denied...

When the dispute is solely about the amount of payment allowed, then the next step is filing an IBR.  All other disputes regarding payment for medical-legal services require a Petition of Determination, along with an accompanying Declaration of Readiness to Proceed, filed with the WCAB.

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