Miralda De La Cruz v. Sunrise of Edina and Sedgwick Claims Mgmt. Servs., Inc.

Miralda De La Cruz v. Sunrise of Edina and Sedgwick Claims Mgmt. Servs., Inc., No. WC12-5530 (WCCA, Aug. 9, 2013)

This is a case in which the employee filed a medical request seeing approval of a MedX Program as recommended by Physicians’ Diagnostics and Rehabilitation (PDR), after sustaining an admitted December 6, 2011 injury to her low back.

The employee underwent various treatment modalities, including chiropractic care and occupational medicine care, including physical therapy in 2012.  Initially, the work hardening program did not work and therefore the employee was referred to PDR because of non-improving back pain.

In an initial consult, Dr. Kraemer of PDR recommended the MedX Program, which would be twice a week for 8 to 12 weeks, depending on progress.

After that, the employee filed a medical request and the employer and insurer filed a response denying the employee’s request to participate in that program due to the fact that the employee had already received 12 weeks of passive treatment and therefore, further passive treatment would be barred by the treatment parameters. They specifically said in Minn. R. 5221.6200, subp. 3, which does put a limit of 12 weeks for passive care once those have been initiated.

The employee did undergo an independent medical examination with Dr. Paul Wicklund, who opined that the employee had subjective low back pain without objective findings and felt that the employee had the temporary strain type injury, which was no longer a substantial contributing cause to the employee’s condition.

He believed that no further treatment was recommended or needed.

At the hearing, there is a dispute with regard to whether treatment parameters apply for the    MedX treatment and whether or not that MedX treatment is reasonably required to cure and/or relieve the effects of work injury.

The employer and insured argued that the Minnesota Rules would not permit additional passible treatment through the MedX Program and that it was not reasonable and necessary treatment.  In fact, the employer and insurer pointed to Dr. Wicklund’s opinion stating that the ongoing compliance was no longer related to the temporary injury sustained on 12/6/2011.

The compensation judge first determined that because Dr. Wicklund had opined that the employee’s injury was a back strain that had resolved, then the employer and insurer had to take the position that the work injury was no longer a substantial contributing factor to her condition and therefore pursuant to prior case law, the treatment parameters are not applicable as a defense to the requested medical treatment.

Therefore, the only defenses remained whether or not the treatment in the MedX Program would be reasonable, necessary, and causally related to the work injury and the compensation judge found that it was.

The only issue on appeal was whether or not treatment parameters could apply in a situation such as this where the claim is an admitted claim, but the IME doctor opines that it is a temporary injury only.

The WCCA found that case law is established that where the employer and insurer deny an admitted injury continues to be causally related to the ongoing affects or condition, it is similar to where the employer and insurer deny primary liability and therefore, the treatment parameters are not an applicable defense.  Because the employer and insurer in fact did raise a defense on medical causation and not just the treatment parameters, or in the alternative the reasonableness and necessity of treatment, the treatment parameters which would limit passive treatment modalities included in the MedX Program were not an applicable defense to that treatment at issue.