If a dispute arises as to whether recommended medical care is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is required, the aggrieved party may file an appeal with the OWC medical director.  The medical director will then render a decision regarding the treatment.  The decision of the medical director may be appealed to the workers’ compensation judge.

Here, Claimant’s treating provider recommended an epidural steroid injection (ESI).  Employer’s choice of physician found that this was not reasonable, and Employer therefore denied the injection.  The issue was submitted to the medical director for review of medical necessity and appropriateness.  The medical director found that the ESI was diagnostic and not allowed under the Medical Treatment Guidelines (MTG).

Claimant appealed the medical director’s decision to the workers’ compensation judge.  The workers’ compensation judge found that the medical records and other evidence showed by clear and convincing evidence that the medical director’s decision was not in accordance with the statutory provisions governing the MTG.  The court was persuaded that the decision of the medical director was contradicted by the medical evidence and reversed the decision of the medical director.

Employer appealed the workers’ compensation judge’s reversal of the medical director’s decision.  The appellate court found that the workers’ compensation judge thoroughly examined the medical records and determined that Claimant showed by clear and convincing evidence that the medical director’s decision should be reversed.  Specifically, it the appellate court noted that the ESI provided pain relief and functional improvement, and was not just for diagnostic purposes.  The appellate court therefore affirmed the workers’ compensation judge’s finding to reverse the medical director’s decision.

Thomas v. Marsala Beverage Company