The WCCA upheld the Compensation Judge’s decision finding the employee’s March 2, 2020 doctor’s visit and recommended treatment was not reasonable and necessary for employee’s work injury.
This case involved an Employee who developed a Gillette injury to both upper extremities while working as a meat cutter at Superfair Foods on May 15, 1995.
Employee’s injury while admitted was disputed as to what the injury actually was. In 2012, Dr. Staiger recommended the Employee undergo a left carpal tunnel release and a right carpal tunnel injection. Employer and insurer denied the treatment based on the opinion of Dr. Call, who did not agree the Employee had carpal tunnel syndrome on either side. A hearing was held April 18, 2013, and the Compensation Judge found the proposed treatment was reasonable and necessary. Employee underwent the left carpal tunnel release in January 2014, but did not receive the right carpal tunnel injection.
Employee followed up with Dr. Staiger on February 16, 2014. Employee reported some symptoms remained, but was told the EMG of the right was negative for carpal tunnel. Employee was released to work without restrictions. Employee continued to follow up approximately every year complaining of left wrist pain. Each time Dr. Staiger indicated that nothing could be done. On March 2, 2020 Employee was seen by PAC Trutwin who offered Employee an EMG or median block injections. Employee elected the block injections. Employer and Insurer denied the injections arguing the visit and treatment was not reasonable and necessary.
An administrative conference was held, followed by a hearing at the Office of Administrative Hearings. The Compensation Judge found the March 2, 2020 visit and recommended treatment was not reasonable and necessary. In the finding the Compensation Judge relied on both medical records and the opinion of Dr. Husband who examined the employee and found no evidence that Employee ever had carpal tunnel or required the initial treatment. Regardless, Dr. Husband based his opinion on the assumption that the findings from the 2013 hearing were fact and concluded that further treatment of Employee was not reasonable and necessary.
On appeal the Compensation Judge’s findings were reviewed under the clearly erroneous standard. Whether a treatment is reasonable and necessary is a question of fact for the Compensation Judge to determine, and will only be overturned if not supported by the record.
Employee argued that the Compensation Judge erred because he had received some relief from therapy, because thus far Employee had only undergone therapy and no other forms of treatment, and because follow up visits were reasonable and necessary to diagnose what treatment the Employee may need. Additionally, the Employee argued that because Dr. Husband disagreed with the findings of 2013 than relying on his opinion was an error of law.
The Appeals Court found no error in the Compensation Judge’s decision and indicated that the Employee was only offering different interpretations of the facts, not a mistake thereof. Further, they noted that Dr. Husband’s opinion was based on the hypothetical assumption that the 2013 findings were factually correct, therefore relying on such was not a legal error.
Takeaway: Lack of evidence of improvement in an employee’s condition following exhausted treatment can create grounds to deny coverage, and potentially discontinue service.