Treatment Does Not Need to Have Lasting Benefit

Treatment Does Not Need to Have Lasting Benefit

Posted: May, 2001

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 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 to administer trigger point injections every two to four weeks, indefinitely. On the C-9, the doctor wrote that the trigger point injections provided Cameruca symptomatic relief.

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 the treatment did not provide continuing or ongoing improvement. Treatment was denied. The BWC file review found no substantial benefit from this treatment and denied treatment. Cameruca appealed.

The DHO denied treatment relying on the two MCO reviews and the BWC review. The 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. The 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:

  1. are the medical services “reasonably related to the industrial injury, that is the allowed conditions”?;
  2. are the services “reasonably necessary for treatment of the industrial injury?”; and
  3. is “the cost of such service . . . medically reasonable”?

The Commission’s primary inquiry involved second prong, the reasonable necessity of treatment and required Cameruca to show a “lasting benefit” to demonstrate reasonable necessity.

The Magistrate finds that an error. The Commission presented no authority for a “no lasting benefit” standard.

The 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 them outside the scope of being reasonably necessary.

The Commission’s reliance on the MCO peer reviewer Dr. H strongly suggests the Commission also based the denial of treatments on the failure of the treatments to show medical improvement.

Magistrate says this was also error. 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.

Information courtesy of the Ohio Workers’ Compensation Bulletin. Subscribe to the Ohio Workers’ Compensation Bulletin to keep informed about the Ohio workers’ compensation system.