Navigating Workers’ Compensation Medication Denials: A Guide to Your Rights and Remedies

Matthew Mosher • February 8, 2024

Serving Our Neighbors Across Western New York

Schedule a Free Consultation

Navigating Workers’ Compensation Medication Denials: A Guide to Your Rights and Remedies

When an employee sustains a workplace injury, access to appropriate medical treatment is vital for a speedy and effective recovery. However, there are instances where workers' compensation claims, specifically those related to medication, face denials. In this blog post, we'll delve into the common reasons behind medication denials and outline the steps you can take to address this issue and secure the treatment you need.

Understanding Medication Denials:

Workers' compensation medication denials can occur for various reasons, often leaving injured workers without the necessary prescriptions to manage pain, reduce inflammation, or promote healing. Common reasons for medication denials include:


  1. Formulary Restrictions: The NYS Workers’ Compensation Board has implemented a Drug Formulary requiring all physicians to follow for prescribing medication. Your doctor must start by prescribing a medication that is listed as a First Line medication for your medical needs.  If the doctor prescribes a Second Line medication without a medication being trialed from the first line of medications, the request will be denied.
  2. Lack of Medical Necessity Documentation: Insufficient documentation regarding the medical necessity of the prescribed medication can be a reason for denial.  Your doctor must provide clear and comprehensive evidence supporting the medical necessity for the prescribed medication.
  3. Treatment Outside of Work-Related Injury Scope: If the prescribed medication is deemed unrelated to the work-related injury, the insurance company may deny coverage. It's essential to establish a direct connection between the medication and the workplace incident.


Medication requests are governed by the New York State Drug Formulary.  Providers must request access from New York State in order to gain access to the system.   Many medications contained in and consistent with the Formulary do not require prior authorization from the Insurance Carrier.  All other requests for medications must be submitted through a Medical Portal between the Physician’s office and the Insurance Company.  The initial request through the Portal is a Level 1 request.  The Insurance company will review the request and can either approve or deny the request.  If approved, the medication will be available for pickup at your pharmacy.


If the request is denied by the insurance carrier at Level 1, it is sent to a Level 2 review by a medical professional in the employ of the Insurance Carrier.  This Level 2 review may result in an approval or result in a continued denial of your medication request.


If the Medication request is denied at the First and Second Levels of Review by the Insurance carrier, your doctor can request a Level 3 review where requests are evaluated by the NYS Medical Directors Office.  Encourage your Provider to submit all denials to Level 3 for review because there is a reasonable chance that the Medical Directors Office overturns the Carrier’s denial if properly supported in the medical request by your doctor.


If the Medical Directors Office upholds the denial, that determination is final. The Workers Comp Board does not permit review of these determinations by a Workers Compensation Law Judge.  If the MDO approves the request, you will be able to obtain the requested medication.

Steps to Take When Facing Medication Denials:


  1. Consult with Your Treating Physician: Start by discussing the denial with your treating physician. They can often provide additional documentation and/or clarification regarding the medical necessity of the prescribed medication. Your doctor's input is crucial in addressing the denial.  They will need to refile the request at that point with additional information.
  2. Seek Legal Counsel: Consulting with an experienced workers' compensation attorney is essential when facing medication denials. An attorney can review your case, advise you on your rights, and guide you or your provider through the process on the basis of the denial.
  3. Explore Alternative Medication Options: Work with your treating physician to explore alternative medications that may be in Medical Formulary. Finding acceptable substitutes can be a practical solution to overcome denials.


Facing a Workers' compensation medication denial can be frustrating, but it's crucial to take proactive steps to address the issue. By working closely with your treating physician and seeking legal guidance, you can navigate the process and fight for the medical treatment you need to recover from a work-related injury.  Often times, if the Insurance company is fighting to deny your medication, they will often be denying medical treatment and lost time next.  Remember, your health and well-being are top priorities, and you have rights to ensure that you receive the appropriate medical care.

Sidewalk Injuries

By Matthew Mosher • September 11, 2023
In New York State, the responsibility for maintaining and repairing sidewalks can be a complex issue. The liability shifting provisions act to determine who should be held accountable for injuries or damages caused by sidewalk defects. These provisions establish guidelines regarding the responsibility of property owners, tenants, and the local municipalities. The most important issue is that differing municipalities have different rules regarding liability for defects on public property like sidewalks. In certain cities, the responsibility for sidewalk maintenance rests solely with the contiguous property owner. This means that if a defect exists on a sidewalk adjacent to a private property, the owner of that property is generally liable for injuries or damages resulting from the defect. However, the situation is not the same in every city. In some cities, liability for sidewalk defects is primarily placed on the local municipalities. Many cities have not yet adopted guidelines shifting liability to the adjacent private landowners. Further, many of those cities have adopted “actual written notice” provisions shielding those municipalities from liability unless a citizen has provided written notice of the specific defect to the municipality before the fall and injury occur. This is often a difficult standard to meet. Additionally, it's worth mentioning that the liability shifting provisions may also depend on the type of property involved. For example, residential property owners may have different responsibilities compared to commercial property owners. It is advisable to consult local laws and regulations or seek legal advice when dealing with specific cases. The liability shifting provisions in New York State for sidewalk defects differ widely from city to city.. In Niagara Falls, New York for instance, property owners are generally responsible for sidewalk maintenance, while in other municipalities, the liability falls on the local government. Exceptions and limitations exist, such as local ordinances that shift responsibility onto property owners, actual written notice provisions, and special use exceptions. Understanding these provisions is crucial for determining liability in cases of sidewalk defects and seeking appropriate legal recourse if necessary. The lawyers at Viola, Cummings, Lindsay LLP can help you sort through all these legal issues after a sidewalk injury and fight for the compensation you deserve.

Spousal Liability Coverage in New York State

By Matthew Mosher • January 30, 2020
Is your wife/husband an awful driver? You know the situation. You’re in the passenger seat with your spouse driving. You’re not paying attention because as the passenger, you don’t have to. So, you’re scrolling through your Facebook feed or adding photos and captions to your Instagram story while your spouse is supposed to be paying attention to the road. Instead, you hear the rumble strips, notice the car is slowly veering off the road, and you look over to see your spouse taking a selfie using the doggy Snapchat filter. If this happens, and you’re injured as a result, you will not be permitted to recover compensation for your injuries unless you have purchased supplemental spousal liability coverage. Your traditional automobile liability insurance policy in New York State will not permit you to recover if you are injured by your spouse’s negligence. Your insurance carrier is required to notify you of this coverage in writing. New York State Insurance Law § 3420(g)(2) states, in relevant part: (2) Upon issuance of a motor vehicle liability policy that satisfies the requirements of article six of the vehicle and traffic law and that becomes effective on or after January first, two thousand three, pursuant to regulations promulgated by the superintendent, the insurer shall notify the insured, in writing, of the availability of supplemental spousal liability insurance. Such notification shall be contained on the front of the premium notice in boldface type and include a concise statement that supplementary spousal coverage is available, an explanation of such coverage, and the insurer’s premium for such coverage. Subsequently, a notification of the availability of supplementary spousal liability coverage shall be provided at least once a year in motor vehicle liability policies issued pursuant to article six of the vehicle and traffic law, including those originally issued prior to January first, two thousand three. Such notice must include a concise statement that supplementary spousal coverage is available, an explanation of such coverage, and the insurer’s premium for such coverage.

Introducing Complex Case Themes During Opening Statements

By Matthew Mosher • December 18, 2019
A. Capture the Audience in The First 30 Seconds

Supplemental Underinsured Motorist Coverage in New York State

By Matthew Mosher • November 17, 2019
This will be the first in a series of posts about various aspects of personal injury law and practice in New York. Some, like this one, will contain information important to non-lawyers (actual humans with feelings and stuff) and others will be only for fellow law nerds looking for a primer on a particular issue. The first topic I’ll be discussing will be Supplemental Underinsured Motorist Coverage in New York State. This one is for everyone. I’m sure you can barely contain your excitement. The most important thing you need to know about Supplemental Underinsured Motorist Coverage (also known as SUM or UIM to all the cool law folks) is that you absolutely, positively need to have this coverage. Underinsurance coverage in New York State is optional, which means the insured must request this coverage and pay the additional premium or the protection will not be provided. The good news is that this coverage is inexpensive. This coverage applies if the other driver is covered by a policy of insurance, but the limits are inadequate to properly compensate for the injuries sustained by the injured party. The scenario is as follows: Defendant is, to use a technical legal term, “a crappy driver.” Maybe he or she has had prior accidents, several traffic violations, or even prior convictions for Driving While Intoxicated. Because of their horrible driving record, this driver has difficulty obtaining liability insurance for their vehicle, and the insurance they do obtain is usually for the minimum in New York State which is $25,000.00. So now, this horrible driver is driving around with very little insurance to protect you and your family. Let’s say this driver keeps up with his tradition of being a crappy driver and slams into the back of your minivan while he’s checking his Twitter feed on his phone instead of looking at the road. If this collision causes you or your family serious injuries, the most you’ll ever be able to recover in a lawsuit against him is $25,000.00 per injured party with a total limit of $50,000.00 for all injured parties. We all know that $25,000.00 doesn’t go very far these days. This is where Supplemental Underinsured Motorist Coverage comes into play. After receiving that $25,000.00 and getting consent from your own insurance carrier to do so, you can make a claim against your own policy of SUM coverage. You are still required to prove all the elements of your lawsuit, but now the entity paying the award is your own insurance company. This payment from your own insurance company comes without a rate increase and is often much easier to obtain than the direct action against the defendant.
Share by: