Do All Medical Procedures Have to Be Pre-approved for Workers’ Compensation?

March 18, 2025 | Workers’ Compensation

Do All Medical Procedures Have to Be Pre-approved for Workers’ Compensation?

The Pennsylvania Workers’ Compensation Act requires most employers to have workers’ compensation insurance for their employees. Workers’ comp pays benefits for and to injured workers, including medical treatment. Workers may misunderstand the rules about obtaining pre-approval for medical procedures for a work injury. In this blog, our York workers’ compensation lawyers explain pre-approval for medical procedures for workers’ compensation.

What Is the 90-Day Rule for Medical Care After a Work Injury in Pennsylvania?

Some of the confusion about pre-approved medical treatments in workers’ compensation has to do with the 90-day rule. However, this rule has nothing to do with pre-approval for medical treatments. Instead, it deals with choosing a doctor in a workers’ compensation case.

Employers are required to post a list of at least six medical providers approved to provide care for work injuries. The list must include no more than two providers who are a Coordinated Care Organization. At least three of the providers must be physicians.

For the first 90 days after a work injury, employees must choose a doctor from the approved provider list. If a worker seeks treatment from a provider not on the approved list within the first 90 days, the insurance company can deny payment. The denial does not relate to the treatment provided but to the fact that the provider is not an approved provider.

An employee can choose to see any doctor of their choice during the first 90 days. However, neither the employer nor the insurance provider is obligated to pay the bill. After the initial 90 days, the employee may seek medical treatment from a licensed medical provider they choose, even if the provider is not included on the approved provider list.

However, the workers’ comp insurance company is only obligated to pay for medical treatment that is reasonable and necessary. Therefore, the company may deny a charge on the basis that the treatment was not reasonable or necessary.

What Does It Mean for Medical Treatment to be Pre-Approved for Workers’ Compensation in Pennsylvania?

Pennsylvania workers’ compensation laws do not require workers to obtain pre-approval for medical care. A problem may arise if a doctor calls the workers’ comp insurance company for pre-approval of medical treatment. The law does not require the insurance company to provide pre-approval. The insurance company is only required to tell the medical provider whether there is an open, payable claim or not.

Unfortunately, a medical provider may not want to provide treatment to an injured worker if they cannot obtain pre-approval for the treatment from the workers’ comp carrier. Generally, doctors familiar with the workers’ compensation system understand the insurance company must pay for necessary and reasonable care. Therefore, the doctor will proceed if they know the treatment is reasonable and necessary.

If a doctor refuses to provide care because it is not pre-approved, there is not much that can be done. The law does not force the insurance company to provide pre-approval, nor does it force the doctor to provide care. There is a utilization review process for obtaining pre-approval for treatment, but that could take several months.

An attorney may be able to help. They can explain workers’ comp laws to the doctor. Some doctors may change their minds and provide care. If your doctor continues to refuse care, you may need to find another provider.

What Happens if the Workers’ Comp Insurance Company Denies Surgery?

A common problem is pre-approval for surgery. Many medical providers require pre-approval from an insurance carrier before performing surgery. They want pre-approval because surgeries are expensive. A worker may not be able to find another provider willing to perform the surgery without pre-approval.

In that case, your workers’ compensation lawyer may negotiate with the insurance company to obtain pre-approval for surgery. The attorney can facilitate communication between the doctor and the insurance company to help the company understand why the surgery is reasonable and necessary.

If negotiating does not work, your attorney can file a formal appeal through the Bureau of Workers’ Compensation. There are several levels of appeal if the first appeal is denied.

Talk With a York Workers’ Compensation Lawyer for a Free Consultation

while the Pennsylvania Workers’ Compensation Act does not require pre-approval for most medical treatments, confusion can arise, particularly with the 90-day rule and the need for pre-approval for specific procedures like surgery. If your medical provider or insurance company is reluctant to proceed without pre-approval, it’s crucial to consult with an experienced workers’ compensation attorney. They can help you navigate the system, negotiate with the insurance company, and ensure that you receive the necessary treatment. If needed, your lawyer can also assist with filing appeals to secure the care you deserve.

If you’ve been injured in a workers’ compensation, please contact Marzzacco Niven & Associates at the nearest location to schedule a free consultation today:

Harrisburg Law Office
945 East Park Drive, Suite 103 Harrisburg, PA 17111
(717) 231-1640

York Law Office
2550 Kingston Road, Suite 210A York, PA 17401
(717) 995-8998

Wyomissing Law Office
833 N. Park Road, Suite 103, Room A Wyomissing, PA 19610
(717) 388-2325

Chambersburg Law Office
79 St. Paul Drive, Suite 1 Chambersburg, PA 17201
(717) 388-2378

Carlisle Law Office
354 Alexander Springs Road Carlisle, PA 17015
(717) 995-8732

Carbondale Law Office
30 Lincoln Avenue, Suite 101 Carbondale, PA 18407
(717) 995-8810

Lancaster Law Office
2173 Embassy Drive, Ste 123, Lancaster Pa 17603
(717) 616-2954

Lebanon Law Office
937 Willow Street, Suite D Lebanon, PA 17042-1140
(717) 995-8963