Appeals of Medical Utilization Reviews and Weight Afforded the MUR Panel

Under the Medical Utilization Reviews (“MUR”) provision of the Act, either the claimant or the respondents may seek review of a MUR panel’s recommendation and a Director’s order before an ALJ. When doing so, the conclusions of the MUR committee are “afforded great weight,” and the party disputing the finding by the MUR committee has the burden of overcoming the finding by clear and convincing evidence.

In Grammer, the claimant suffered multiple work-related injuries for which she eventually developed complex regional pain syndrome (CRPS). Her symptoms continued to worsen and by 2008 she was no longer able to work. Thereafter, claimant moved to Nevada and began seeing a physician who treated her pain with platelet rich plasma (PRP) injections. By 2014, he had performed over 100 injections. This is relevant because under the Colorado Medical Treatment Guidelines, only 3 injections are deemed “reasonably and necessary.” Accordingly, respondents questioned the reasonableness and necessity of so many PRP injections by applying for a hearing. The ALJ agreed that so many injections were not “reasonably and necessary” and ordered the physician to discontinue the treatment method. However, the physician continued to perform these injections on the claimant despite the ALJ’s order.

As a result, respondents were forced to challenge these continued treatments through an MUR. All three physicians on the review panel opined that such an amount of PRP injections were not “reasonable and necessary” and recommended a change of provider. Consequently, the Director issued an order consistent with those recommendations. Claimant appealed the Director’s order to an ALJ who also agreed with the previous opinions. Importantly though, during this appeal, ALJ did not conduct a hearing. Rather, pursuant to MUR statute, he made his ruling based on a review of the record. Claimant challenged the ALJ’s opinion in the Industrial Claim Appeals Office (Panel), which affirmed the ALJ’s ruling. Claimant then appealed the decision of the Panel to the Colorado Court of Appeals.

Claimant argued the MUR statute unconstitutionally violated her constitutional right to due process by depriving her of a protected property interest without a hearing. She asserted her workers’ compensation benefits were constitutionally protected and the MUR statute deprived her of due process by omitting an avenue for a claimant to request a hearing to challenge an MUR committee’s recommendations. The Court held she did not meet the threshold burden required to challenge a statute under the theory of deprivation of property. To do so, a claimant must demonstrate the statute is unconstitutional beyond a reasonable doubt, which is one of the highest standards of proof in the United States judicial system. Furthermore, the Court relied on previous Colorado Supreme Court precedent which held that no workers’ compensation claimant has a property interest in receiving a particular type of treatment from a particular physician. Expanding on that, the Court reasoned that while workers’ compensation benefits are indeed a protected property interest, such interest is not impinged a myriad other treatments and a myriad of physicians were available for treatment of her disability. Therefore, preventing her from receiving this specific treatment from one specific physician was not a constitutional violation.

Lori Madden-Grammer v. ICAO; Poudre Valley Hospital; and Colorado Hosptial Association Trust, W.C. 3-928-088, No. 17CA2066 (Colo. Ct. App. Dec. 13, 2018)

Would you like to know more? Contact Tucker E. Allen at tallen@pollartmiller.com or 877-259-5693.

 

From the January 2019 Pollart Miller Newsletter

2019-02-01T15:09:57+00:00