Kentucky Workers’ Comp Medical Denials: How to Appeal

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

If you were hurt at work in Kentucky, your medical care is usually paid by your employer’s workers’ compensation coverage, not your health plan. When that coverage says no to a test, a surgery or more therapy, the rules for fighting back are different from health insurance appeals. The deadlines are also much shorter.

This guide explains how Kentucky workers’ comp medical denials work and how to appeal them, step by step. It is part of the Coverage & Appeals Center. For health insurance appeals in Kentucky, see how to appeal in Kentucky.

Who pays for care after a work injury

Kentucky law says your employer must pay for medical, surgical and hospital treatment that is reasonably needed to treat a work injury or occupational disease (KRS 342.020). In practice, the employer’s insurance carrier (or the employer, if it is self-insured) pays the bills.

A few key points from the same law:

• Choosing a doctor. If your employer has not named a managed health care system, you may choose your own medical providers. If it has, you can still keep seeing a doctor who gave you emergency care (KRS 342.020).
• Payment goes to the provider. The employer or its insurer must pay your provider directly, within 30 days of getting a bill.
• Medical care can continue for years. How long depends on the type of award.

Whether a clinic can bill you directly for a work injury while the claim is open is a billing question. Ask the clinic and the insurer in writing.

Kentucky workers’ comp medical appeals at a glance

Kentucky renumbered its workers’ comp regulations effective June 29, 2026. Rules once cited as 803 KAR 25 are now 120 KAR 1. Older letters and websites may still use the old numbers. The rules are the same ones, under a new number.

Step 1: Utilization review and reconsideration

Most medical denials in Kentucky workers’ comp start with utilization review. This is a check by a reviewer working for the employer’s insurer. They decide whether a treatment is reasonable and necessary.

If the reviewer says no, you get a written Notice of Denial. By rule, it must include (120 KAR 1:195, Section 7):

• The medical reasons for the denial.
• The name, state of licensure and license number of the reviewer.
• An explanation of your right to ask for reconsideration.

If your letter is missing these, write that down. It may matter later.

1. Find the date you got the denial. Your 10-business-day window starts when you receive the written Notice of Denial (120 KAR 1:195, Section 8). Mark the last day on your calendar.
2. Copy the exact reason. Write down the medical reason the reviewer gave. Your request should answer that reason, not argue in general.
3. Call your treating doctor’s office. Ask them to send records and a short letter that explains why the treatment is needed. Ask if they want a peer-to-peer call with the reviewer.
4. Send your written request. Use the address, fax or portal listed on the denial. Keep proof you sent it.
5. Expect a different reviewer. A different reviewer of the same medical specialty decides. The answer is due within 7 business days, or 5 business days after a peer-to-peer call.
6. Keep the final UR decision. You will need it if you take the dispute to a judge. A Form 112 must include it (120 KAR 1:012).

If waiting could lead to serious disability, your provider can ask for an expedited review. The rule says that decision is due within 24 hours (120 KAR 1:195, Section 5).

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Insurance carrier or utilization review company name]
[Address or fax from the Notice of Denial]

RE: Request for reconsideration of utilization review denial
Injured worker: [Name]
Employer: [Employer name]
Claim number: [Number]
Date of injury: [Date]
Treatment denied: [Treatment]
Treating provider: [Name, credentials]
Date I received the Notice of Denial: [Date]

To whom it may concern:

I request reconsideration of the utilization review decision denying [treatment]. The Notice of Denial says: "[exact reason]."

I am making this request within 10 business days of receiving the written denial.

My treating provider believes this care is reasonable and necessary to treat my work injury. Enclosed are:
- A letter from [provider] that answers the denial reason
- Medical records from [dates]
- A list of treatment I have already tried, with dates and results
- A copy of the Notice of Denial

[Optional:] My provider asks for a peer-to-peer conference with the reviewer. Please call [office phone].

Please send me a written decision. If the denial is upheld, please send the final utilization review decision and the reviewer's name and specialty.

Sincerely,
[Signature]
[Printed name]

Step 2: A medical dispute before a judge

If reconsideration does not fix the problem, the next step is a medical dispute. In Kentucky, a disagreement about whether treatment is reasonable, necessary or work-related is decided by an Administrative Law Judge (ALJ). It starts when someone files a Form 112 (Medical Dispute) (120 KAR 1:012).

What to know about Form 112:

• Who can file. The employee, the employer, the insurance carrier or the medical provider.
• What it needs. The disputed bills, a sworn statement of the facts, the medical opinion that supports your side, and the final UR decision.
• UR comes first. If the treatment is subject to utilization review, a medical dispute cannot be filed until UR is finished.
• The employer’s clock. The employer or its payer has 30 days after the final UR decision to file a medical dispute.
• After a case is closed. If your claim already ended with a final order, a motion to reopen is filed along with the Form 112 (120 KAR 1:012; KRS 342.125).

Which side should file, and when, depends on your case.

1. File your claim if you haven’t. A claim is started with an Application for Resolution of a Claim – Injury, filed with the Department of Workers’ Claims. Self-represented workers can file on paper or online (DWC: How to File a Claim). The filing deadline is generally 2 years (KRS 342.185).
2. Go through the ALJ process. An ALJ holds a benefit review conference and a hearing, then decides. The Department says the decision comes within 60 days after the hearing (DWC: How to File a Claim).
3. Ask the ALJ to fix clear errors. Within 14 days of the decision, any party can file a petition for reconsideration. It is only for errors that are plain on the face of the decision (KRS 342.281).
4. Appeal to the Workers’ Compensation Board. File a Notice of Appeal within 30 days of the ALJ’s final decision, or of the order on a petition for reconsideration (120 KAR 1:010, Section 22). The Board does not take new evidence (KRS 342.285).
5. Go to the Court of Appeals. The Board’s decision can be reviewed by the Kentucky Court of Appeals (KRS 342.290). The Board’s handbook says this is within 30 days after the Board’s opinion. The Kentucky Supreme Court comes after that (WC Board Appeals Handbook).

Kentucky’s official form and claim page use the name “Application for Resolution of a Claim.” Separate versions exist for hearing loss and occupational disease (DWC: How to File a Claim).

How workers’ comp and your health plan fit together

This is one of the most confusing parts of a work injury. Workers’ comp is generally the payer for care for a work injury. Many health plans say they do not cover work injuries. But when a comp claim is denied or still in dispute, people often don’t know who should pay in the meantime.

Some general tips:

• Tell every provider it’s a work injury. Give them your claim number and the insurer’s name.
• Keep the comp denial letter. Your health plan may ask for it before it will look at the bill.
• Read your health plan’s rules. Look in your plan documents for language about work-related injuries.
• Watch for repayment requests. If your health plan pays and comp later accepts the claim, one may ask the other to repay.

Hurt in a car crash while working? Kentucky’s auto no-fault law subtracts workers’ comp benefits when it figures what PIP pays (KRS 304.39-120). See auto injuries and PIP.

A Kentucky workers’ comp denial, start to finish

*This is an illustrative example, not a real patient.*

• May 5: Jordan, a warehouse worker in Louisville, hurts a shoulder lifting boxes. The employer’s carrier accepts the claim and pays for early visits.
• May 27: Jordan’s doctor asks for an MRI. On June 1, Jordan gets a Notice of Denial that says “conservative care not documented.”
• June 3: Jordan counts 10 business days from June 1 and marks June 15 on the calendar. Jordan asks the doctor’s office for therapy notes and a short letter.
• June 8: Jordan faxes a reconsideration request with the letter and notes, and saves the fax confirmation.
• Within 7 business days: A different reviewer of the same specialty decides. If the denial stands, Jordan keeps the final UR decision for a Form 112.

If the reconsideration fails, the dispute goes to an ALJ. Jordan would then have 14 days to ask the ALJ to fix a clear error and 30 days to appeal to the Board.

Common mistakes

• Treating the denial like a health insurance appeal. Health plans often allow 180 days. Kentucky UR reconsideration allows only 10 business days.
• Counting calendar days. UR deadlines are in business days. Count carefully, and file early.
• Skipping utilization review. A Form 112 can’t be filed until UR is finished, if the treatment is subject to UR (120 KAR 1:012).
• Losing the final UR decision. A Form 112 must include it.
• Bringing new evidence to the Board. The Board reviews the record from the ALJ. Get your evidence in front of the ALJ.
• Using the old regulation numbers. 803 KAR 25 is now 120 KAR 1. The content still applies.
• Missing the 2-year claim deadline (KRS 342.185).

Where to get help

Kentucky’s workers’ comp system is run by the Department of Workers’ Claims. Since April 9, 2026, it has been an independent department attached to the Office of the Governor. It is no longer part of the Education and Labor Cabinet (SB 343, 2026 Ky. Acts ch. 61). For now, its web pages are still on the Education and Labor Cabinet’s website (elc.ky.gov).

The Department lists toll-free help from its specialists at 800-554-8601 (DWC: How to File a Claim). The Board’s appeals handbook explains the appeal steps in more detail (WC Board Appeals Handbook).

For a health plan denial that is not a work injury, use the appeal route wizard or the appeal deadline calculator. If you need therapy after a work injury, see getting physical therapy covered. Working in Indiana? See Indiana workers’ comp medical appeals.