The claimant sustained an admitted thoracic back injury when he slipped and fell at work. Throughout his course of treatment, claimant’s pain complaints were consistently reported at 10/10, despite documentation of normal vital signs and normal presentation. Numerous diagnostic studies were negative and multiple physicians documented pain out of proportion to objective findings with an unknown etiology of pain. Claimant’s ATP requested a second opinion in the form of a neurology consultation, despite the fact that no provider had documented any neurological symptoms or deficits. Instead of simply making the referral, the ATP requested authorization for the neurology consultation.
Respondents obtained an IME and informed both claimant and the provider that authorization would not be given on the basis that treatment by a neurologist was not reasonable, necessary, or related to the work injury. Claimant sought treatment with a neurologist under his private health insurance and the neurologist then referred claimant to a pain management specialist. The case proceeded to hearing with the being: whether the referral to a neurologist and subsequent referral to a pain management specialist is reasonable and necessary care under the Act?
At hearing, Respondents conceded that a referral made by an ATP is technically authorized and within the chain of referral. However, Respondents argued that they retain the right to challenge whether the treatment provided was reasonable, necessary and related. With the case of a simple referral to a specialist, this often occurs at the time Respondents are billed for the visit, at which point Respondents can evaluate the treatment provided and determine whether to pay or deny the bill. In this particular case, Respondents were requested to provide prior authorization – or a promise to pay up front. Respondents denied the request for authorization. At hearing, claimant argued that the referrals were within the chain of referral because they were made by the ATP and because a second opinion was reasonable and necessary given that the ATP had been unable to determine a cause of claimant’s ongoing pain following the work injury. Respondents argued that the referrals were not reasonable, necessary, and related given that claimant had no neurological findings to support an evaluation by a neurologist and that, in general, claimant could not establish causation given that the etiology of his pain was unknown. Respondents also pointed to numerous medical records which called claimant’s pain complaints and possible secondary gain motivations into question. The ALJ agreed with Respondents and held that determination of whether a particular treatment modality is reasonable and necessary to treat an industrial injury is a factual determination for the ALJ, and claimant failed to meet his burden in this case. McGill v. Kroger Co. W.C. No. 5-033-311 (ICAO August 14, 2017)
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