Proving that Medical Treatment is Necessary to Cure a Work Injury

In Foust, a hearing was held to determine whether Claimant had demonstrated that a left total shoulder replacement, as recommended by his surgeon, was reasonably medically necessary to cure and relieve his work injury.  Following hearing, the administrative law judge (“ALJ”) found the surgery necessary and ordered respondent pay for the replacement.  Respondent sought a review of this order with the Industrial Claim Appeals Office (“Panel”). 

The facts in Foust are as follows: Claimant worked for employer delivering freight, loading and unloading items, at various locations for over a decade.  On July 15, 2019, claimant was unloading kayaks when one, weighing about 80 pounds, slipped behind him and struck him on the upper left part of his back.  Following care and diagnostic testing, claimant underwent a left shoulder arthroscopy with rotator cuff repair.  However, while Claimant was under anesthesia, his surgeon realized that the rotator cuff did not need to be repaired, but found instead there was “bone on bone arthritis” which would require a whole shoulder replacement.  The surgeon submitted an authorization request for a shoulder replacement the same day. 

At the request of Respondent, Claimant underwent an independent medical examination (“IME”). The IME physician opined that Claimant may have suffered a minor strain or sprain as a work injury, but that the work injury had resolved.  The IME physician noted that Claimant had significant osteoarthritis in his left shoulder, but that it was chronic and not the result of the work injury. The IME physician stated that the shoulder replacement was reasonable, but not related to his work injury. 

However, at hearing, the ALJ issued an order determining that Claimant’s need for a total left shoulder replacement was related to the admitted work injury. ALJ looked to Claimant’s testimony, medical records, and the opinions of the surgeon to determine that Claimant’s asymptomatic preexisting left shoulder arthritic became symptomatic because of the work injury. Therefore, ALJ concluded it was reasonable, related and necessary for Claimant to undergo a full shoulder replacement.  Respondent appealed this finding to the Panel, arguing that the ALJ’s factual findings were unsupported by substantial evidence and that the ALJ disregarded the Workers’ Compensation Rule of Procedure 17 Guidelines (“Guidelines”) in determining that Claimant needed the total shoulder replacement. 

First, the Panel found that the ALJ’s determination relied upon substantial evidence.  By relying upon Claimant’s testimony and medical records, as well as the medical opinion of Claimant’s surgeon, the Panel explained that the ALJ’s findings were supported by substantial evidence.  The Panel cannot disturb an ALJ’s findings if those findings are supported by substantial evidence.  Therefore, the Panel did not disturb the ALJ’s findings that whole shoulder replacement was necessary treatment for Claimant. 

Respondent also argued that ALJ made no factual findings regarding the Guidelines; specifically stating that no legal conclusions that the surgery was necessary and reasonable were made under Guidelines.  Respondent argued that this rendered the ALJ’s order “unsupported by law.”  The Panel explained that the Guidelines are regarded as accepted professional standards of care under the Workers’ Compensation Act, and an ALJ may consider the Guidelines when determining when a specific treatment is reasonable and necessary.  In this case, the IME physician opined that Claimant’s surgeon did not comply with the Guidelines prior to recommending a whole shoulder replacement.  The ALJ considered this opinion and the Guidelines, but was not persuaded by the IME physician.  The Panel explained that the ALJ had considered the Guidelines in deciding whose medical opinion was most credible.  Through substantial evidence and consideration of the Guidelines, the ALJ acted properly when it decided that a whole shoulder replacement was necessary and reasonable treatment for Claimant’s work injury. 

For those reasons, the Panel rejected both of Respondent’s arguments that ALJ had erred in ordering the whole shoulder replacement as treatment for Claimant’s work injury. The Panel affirmed the ALJ’s order. 

Foust v. YRC Freight, W.C. No. 5-113-596 (I.C.A.O. October. 21, 2020)

Want to know more? Contact Brianna Tancher at btancher@pollartmiller.com or 877-259-5693.

November 2020 Newsletter

2020-12-30T11:41:05+00:00