This case involved an employee who suffered an admitted ankle injury which led to a diagnosis of complex regional pain syndrome (CRPS). The employee’s claim was settled in 2004 with future medical benefits left open and the employer and insurer agreeing to pay for future reasonable and necessary medical benefits. Over the next ten-plus years, the employee continued treating for his condition through use of opioid medications as well as other treatment modalities but was never able to eliminate his symptoms.
The employer and insurer sent the employee for an IME in 2016 and this was the first IME report that cast doubt on the diagnosis of CRPS. Based on that opinion, the employer and insurer began denying the employee’s ongoing treatment and medications for CRPS and requested the employee’s treating provider to comply with the treatment parameters for long term opioid use.
At hearing, the employer and insurer argued that the employee’s CRPS condition (not the overall ankle injury, which is important) had resolved, his treatment wasn’t reasonable or necessary and his continuing medications were not in compliance with the treatment parameters. The compensation judge found that asserting the employee’s CRPS condition had resolved counted as a denial of primary liability such that the treatment parameters did not apply and the employer and insurer were ordered to pay for the employee’s medications and treatment.
The WCCA agreed and the employer and insurer appealed to the Supreme Court only on the issue of whether or not the treatment parameters should apply in this case.
The Supreme Court disagreed with the compensation judge and the WCCA and held that the bar against applying the treatment parameters applies only when an employer and insurer deny liability for an injury. The Supreme Court opined that since the employer and insurer here didn’t deny the injury and didn’t argue that the injury was fully resolved, their position that the treatment requested isn’t reasonable and necessary based on their IME opinion that the CRPS diagnosis had resolved, did not count as a denial of liability. In a footnote, the Supreme Court stated that their decision “might be” different if the employer and insurer had argued that the employee no longer suffered from any symptoms related to the work injury, but that wasn’t the case here – the employer and insurer didn’t make the argument that the injury had resolved, only that the CRPS condition had resolved, and that’s not enough to satisfy the “denial of liability” component in the Rules to trigger the bar against applying the treatment parameters.
This case should not be interpreted to give employers and insurers broad range to argue a resolved temporary aggravation or temporary injury and still rely on the treatment parameters because, though the Supreme Court did not address that exact issue, their footnote leaves the issue open by saying their opinion might have been different under those facts.
After this decision, employers and insurers will be able to rely on treatment parameter arguments if they continue to admit the underlying injury but dispute a particular condition or diagnosis related to that injury and the treatment related specifically to that condition or diagnosis – so this decision already has a fairly limited scope of applicability. We should expect additional litigation on this issue and anticipate that subsequent WCCA decisions may aim to clarify, and further limit, the positions employers and insurers can take while continuing to rely on the treatment parameters.