Medical Director’s Decision Insufficient to Justify Denial

Claimant began receiving medical treatment following an injury she incurred while in the course and scope of employment.  On August 25, 2014, one of Claimant’s treating physicians prescribed an adjustable mattress. On September 17, 2014 another one of her treating physicians also prescribed Claimant an adjustable mattress.  The prescriptions were faxed to the third-party administrator.  The third-party administrator’s utilization review company recommended a denial of the request for the adjustable mattress stating that there was no medical rationale supporting the medical necessity of the bed submitted by the treating physicians and further stated that the request does not meet the Louisiana Workforce Commission Medical Treatment Guidelines based on the absence of the required documentation to support requests for medical treatment.

Following this recommendation, the claim was denied.  Claimant sought review of the denial by the Medical Director.  In denying the request, the Medical Director stated the general rule that “It is generally felt that large expenses such as spas, whirlpools, and special mattresses are not necessary to maintain a function beyond the areas listed above.” He further determined that the request was not supported, a variance was not requested, and there was no medical evidence demonstrating a variance from the medical treatment schedule.

On May 7, 2015, the workers’ compensation judge found that the Employer failed to reasonably controvert the necessity for the adjustable bed, ordered that the Employer authorize prescription of the adjustable bed, taxed the first treating physician’s expert fee to the Employer, and cast the Employer with penalties and attorney fees in accordance with La. R.S. 23:1201.  The Employer appealed urging that the award of penalties and attorney fees was error, and the Claimant answered the appeal seeking additional attorney fees for the cost of defending the appeal.

On appeal the Court of Appeals for the Third Circuit of Louisiana affirmed the workers compensation judge’s ruling.  It held that the Employer did not have sufficient factual and medical information to justify denial and requested medical treatment.  Rather, the evidence that the Claimant reported to her physicians that lying on her left side decreased pain, she had difficulty sleeping, and she rolled in bed, was substantial.  Additionally there was evidence that her pain increased when lying down.  This evidence made it incumbent on the Employer to reasonably controvert the claim and rebut the presumption created by the evidence.  The Employer failed to present such evidence.  The court further held that the employer’s complete reliance on the decision of the Medical Director that the treatment proposed was beyond the scope of the Medical Treatment Guidelines was improper.  It found the reliance to be a departure from the long-standing jurisprudence requiring that an employer “must rely on competent medical advice when the decision to deny medical treatment is made.”  Because the Employer failed to present sufficient medical information to reasonably controvert Claimant’s request and to dispose of its continuing duty to investigate the claim before denying it, the penalties and attorneys fees imposed by the workers compensation judge were appropriate.  The court also awarded additional attorney fees to Claimant for having to defend the appeal.

This ruling sets precedent that an opinion from the Medical Director controverting the opinions of plaintiff’s treating physicians may be insufficient to justify a denial of recommended treatment and medical equipment.  Employers should be wary not to discount requests for the spas, whirlpools, and mattresses that the general rule highlights as unnecessary.  Employers should give great weight to the recommendations of claimants’ treating physicians, despite the general rule.

Ardoin v. Calcasieu Parish School Bd.