Posted: May, 2001
Treatment Does Not Need to Have Lasting Benefit
State ex. rel. Cameruca v. Indus. Comm. (3/20/01), Franklin No.
00AP-1236 (Magistrate's Decision), adopted by the Court of Appeals on
(6/21/01).Issue: Must an injured worker show that there is a "lasting benefit" resulting from medical treatment to justify authorization of medical services?
Background: Cameruca was injured in 1994. His claim was allowed for sprain neck, sprain thoracic, sprain lumbar, sprain right rotator cuff, right C-6 radiculopathy.
In 1999, his doctor requested authorization of trigger point injections to be administered every two to four weeks indefinitely. On the C-9, the doctor wrote that Cameruca was getting symptomatic relief with the trigger point injections.
The MCO denied the C-9 based on a file review that the requested treatment was not medically indicated. Cameruca appealed through the ADR process. The peer reviewer found that there is not continuing or ongoing improvement with treatment. Treatment was denied. The BWC file review found no substantial benefit from this treatment. BWC denied treatment. Cameruca appealed.
DHO denied treatment relying on the two MCO reviews and the BWC review. DHO found the physicians opined that the treatment did not provide a lasting benefit. Cameruca testified that the injections only provided relief for five or six days at a time. Cameruca appealed. SHO affirmed that the treatment did not provide any lasting benefit. The Commission refused further appeal.
Cameruca filed a mandamus.
Decision: Magistrate recommends Court of Appeals grant mandamus.
Magistrate finds that the Commission applied an incorrect standard in denying the requested medical services. The Supreme Court in State ex rel. Miller v. Indus. Comm. (1994), 71 Ohio St.3d 229, made a three-pronged test for authorization of medical services:
- are the medical services "reasonably related to the industrial injury, that is the allowed conditions"?;
- are the services "reasonably necessary for treatment of the industrial injury?"; and
- is "the cost of such service . . . medically reasonable"?
Magistrate finds that to be an error. The Commission on mandamus presented no authority for its "no lasting benefit" standard.
Magistrate says that temporary benefit treatments are routinely applied in medicine. A medical treatment that only produces a temporary benefit can be reasonably necessary to treat an injury. The fact that trigger point injections only provide temporary relief does not render it outside the scope of being reasonably necessary.
The Commission's reliance on the MCO peer reviewer Dr. H strongly suggests the Commission felt the failure of the treatments to show medical improvement was also a basis for the denial of the treatments.
Magistrate says this was also error. Magistrate says that the definition of MMI says that a claimant may need supportive treatment to maintain a level of function even though the claimant is no longer expected to improve. Therefore the Commission's regulations strongly suggest that a treatment that only maintains a level of function can meet the test of medical necessity.
Editor’s Comment: No objections were filed to the Magistrate's decision. This decision should be helpful in getting treatment allowed for claimants.
This information was provided courtesy
of the Ohio
Workers'
Compensation Bulletin.