Denied Workers’ Comp Care in Maryland? How to Challenge Medical Authorization Decisions

What “medical authorization” means in a Maryland workers’ comp case

In workers’ compensation, employers and insurers commonly review certain treatment requests before they agree to pay. People may call this “authorization” or “preauthorization.” Practically, it is the carrier’s decision process about whether the recommended care is connected to the work injury and appropriate under the circumstances.

Disputes can involve many types of care, including specialist referrals, diagnostic imaging (MRI/CT), physical therapy, injections, surgery, durable medical equipment, prescriptions, and work-conditioning or functional capacity evaluations.

Maryland law generally requires the employer or insurer to provide medical treatment that is reasonably required for the work-related injury. See Md. Code, Labor & Employment § 9-660.

Common reasons treatment gets denied or delayed

Denied care is not always a dispute about whether you are hurt. Often, the carrier’s decision turns on the documentation submitted and how clearly the request links the treatment to the work injury. Common issues include:

• Causation dispute: the insurer claims the condition is not related to the work injury (including disputes involving pre-existing or degenerative conditions).
• Insufficient clinical detail: missing exam findings, imaging reports, objective deficits, prior response to treatment, or a clear diagnosis.
• Medical-necessity dispute: the insurer contends the care is not necessary yet, is duplicative, or lacks a clear treatment goal.
• “Accepted condition” mismatch: the insurer asserts the claim only covers a narrower diagnosis than what the requested care addresses.
• Administrative problems: incomplete forms, unclear frequency or duration, missing records, or coding and processing errors.

Immediate steps to take after a denial

If you learn a treatment request was denied (by letter, portal message, or your provider), move quickly and stay organized.

1) Get the reason in writing

Ask what was denied (specific procedure, number of visits, provider, medication, etc.) and why. If there was a medical review, ask for the reviewer’s rationale and what records were considered.

2) Collect the supporting medical records

Gather the treating provider’s office notes, referral, imaging reports, prior therapy notes, medication history, and work-status notes. Many denials turn on what the reviewer did (or did not) have.

3) Ask your doctor for a focused medical-necessity explanation

A short addendum can help if it squarely addresses: diagnosis; relation to the work injury; objective findings; prior conservative care and response; why the requested care is appropriate now; and measurable goals (function, range of motion, return-to-work capacity).

4) Confirm the request matches the condition(s) at issue in the claim

If the insurer has accepted only part of the diagnosis, it may deny care as outside the covered injury. In some cases, resolving the underlying dispute about the condition may be necessary before treatment is approved.

5) Track functional impact

Keep a simple log of flare-ups, sleep disruption, activity limits, and missed work. This does not replace medical evidence, but it can help your provider describe functional loss and support work restrictions.

How to strengthen an authorization request (before it gets denied)

Well-supported requests can be harder to deny. Helpful elements often include:

• Clear causation narrative: how the work incident caused or aggravated the condition.
• Objective support: exam findings, imaging, test results, documented deficits.
• Treatment history: what has been tried and the response (including why less-invasive care failed or is no longer appropriate).
• Specific plan: frequency, duration, goals, home exercise program, anticipated milestones.
• Work impact: restrictions and how the requested treatment supports safe return to work or prevents worsening.
• Alternative explanations addressed: why symptoms are not primarily unrelated or solely degenerative.

Escalation options in Maryland if the carrier will not authorize care

If the insurer will not authorize recommended treatment, there are typically two practical paths that may be pursued (often in parallel):

• Medical documentation track: your treating provider can submit additional records, clarify the treatment plan, and, where available, request a reviewer discussion to address medical-necessity concerns.
• WCC dispute-resolution track: if the parties cannot resolve the issue, you may be able to bring the dispute to the Maryland Workers’ Compensation Commission for a decision. The Commission’s general authority to decide issues in a workers’ compensation claim is addressed in Maryland’s workers’ compensation law. See, for example, Md. Code, Labor & Employment § 9-742, and the Commission’s public resources at [REFLINK url=”[REFLINK url=””https://www.wcc.state.md.us/””]https://www.wcc.state.md.us/[/REFLINK].

Procedure and evidence requirements can be case-specific. The most efficient next step may be supplementing the medical record, formally presenting the dispute to the Commission, or first addressing a compensability or diagnosis issue that is blocking care.

What to expect if your dispute goes before the WCC

In treatment disputes, the focus is commonly whether the requested care is causally related to the work injury and reasonably required.

• Documentation matters: contemporaneous records and clear medical opinions often carry more weight than general complaints alone.
• Consistency matters: inconsistent histories, gaps in care, or unclear symptom reporting can be cited to support denial.
• The insurer may present contrary medical opinion: carriers may rely on records reviews or independent medical examinations, depending on the case.

An attorney can help assemble records, frame the issue for decision, and coordinate with treating providers so the Commission receives a clear, supported presentation.

Red flags to address early

Certain patterns can repeatedly cause authorization problems:

• Missed appointments or long gaps in care without explanation
• Treatment requests not tied to documented findings
• Changing injury descriptions over time
• Pre-existing conditions not clearly distinguished from work-related aggravation
• Multiple modalities requested at once without explaining sequencing

If any apply, a denial may still be addressed by clarifying the record and tightening the medical support.

FAQ

How long does an insurer have to approve treatment in Maryland workers’ comp?

Timelines can vary by the type of request, the carrier’s internal process, and what information the provider submitted. If care is delayed, ask for the decision and rationale in writing and confirm what records the reviewer considered.

Can I treat anyway and get reimbursed later?

Sometimes people do, but reimbursement can be disputed if the carrier maintains the care was not causally related or not reasonably required. Before proceeding, consider getting a clear written medical rationale and legal advice about the risk in your specific case.

What if the insurer says the treatment is for a “non-accepted” condition?

That commonly means the carrier is drawing a line around a narrower diagnosis than your doctor is treating. You may need medical support explaining the connection, and you may need to resolve the disputed condition as part of the claim before treatment is approved.

Where can I find official information about the Maryland Workers’ Compensation Commission?

The Commission’s official site is [REFLINK url=”[REFLINK url=””https://www.wcc.state.md.us/””]https://www.wcc.state.md.us/[/REFLINK].

When to talk to a Maryland workers’ comp lawyer

Consider legal advice if:

• You are being denied key diagnostics, referrals, or treatment your provider says you need
• The insurer claims the requested care is unrelated to the work injury
• You are stuck between providers and the carrier with no clear next step
• The insurer’s “accepted” diagnosis appears too narrow to cover necessary care
• You are facing pressure to return to work without recommended treatment

Next step: If you want help assessing a denial and the best path forward, contact our office.

Bottom line: denials can be challenged

A denial of medical authorization is often a dispute over proof: medical necessity, causal relationship, and how clearly the request is documented. Many denials can be improved with targeted medical support, and unresolved disputes may be appropriate to present through Maryland’s workers’ compensation process.