Unnecessary for Applicant to Obtain Request for Authorization to Challenge Defendant’s Termination of Medical Treatment

Patterson v. The Oaks Farm (Significant Panel Decision) (___CCC____):

The WCAB held the following:
1. That the provision of a nurse case manager is a form of medical treatment pursuant to LC § 4600.

2. An employer may not unilaterally cease to provide approved nurse case manager services when there is no evidence of a change in the employees circumstances her condition showing that the services are no longer reasonably required to cure or relieve the injured worker from the effects the injury.

3. The use of a hearing to address the medical treatment issue in this case is expressly authorized by LC § 5502 (b) (1).

4. It is not necessary for injured worker to obtain a request for authorization to challenge unilateral termination of services of a nurse case manager.

The WCAB ruled as follows:

1. The provision of a nurse case manager is a form of medical treatment pursuant to LC § 4600. The board found that the defendant recognized the need for the nurse case manager as reasonable medical treatment when an authorized those services. The board indicated the nurse case manager has a singular role to interact and coordinate with the injured employee, injured employees physicians, the claims adjuster, the attorney and others, were all parties to the need for medical treatment. The WCAB agreed the provision of a nurse case manager services is a form of medical treatment as defined in LC§ 4600 (a). The coverage of 4600 extends to any medically related services that are reasonably required to cure or relieve the effects of the industrial injury common even if those services are not specifically enumerated in the section. (Symers v. WCAB 49 CCC 454. The description of medical treatment and 4600 expressly includes nursing services which encompasses the services of a nurse case manager as well as practical nursing services performed by unlicensed persons. (Lamin (30 2CWCR 74), Henson (37 CCC 564), Pacific Electric (15 CCC 88), California Casualty (64 CCC 1176). In this case the defendant acknowledged that the services of a nurse case manager are reasonably required to cure or relieve applicant from the effects of her injury as described in section 4600 when an authorize the provision of those services.

2. An employer may not unilaterally cease to provide approved nurse case manager services when there is no evidence of the change in the employees circumstances or condition showing that the services are no longer reasonably required to cure or relieve the effects of the injury. The WCAB found the defendant admitted it authorize the nurse case manager services as part of applicants medical treatment. Defendants now contend the provision of such services is not supported by substantial evidence. Defendant did not initially claimed stop providing nurse case manager services because there are no longer reasonably required to cure or relieve applicant from the effects of her injury. Instead the attorney stated things frequently change so far as nurse case manager’s participation is concerned again primarily to the fact the applicant is difficult to deal with. Unilaterally terminating medical treatment that was earlier authorized is reasonably required is contrary to section 4600 (a) unless supported by substantial medical evidence. Characterizing a patient is difficult to deal with is not a substitute for medical evidence. Although defendant unilaterally ceased reasonable medical treatment based upon its subjective perception that the injured worker is a difficult person is inconsistent with the use of objective, evidence-based standards to evaluate whether medical treatment is reasonably required to cure or relieve from the effects of the injury. Defendant also misconstrues applicant’s burden in arguing that she was obligated to prove a need for nurse case manager services the S dated hearing. The issue was whether there was good cause to discontinue the services of a nurse case manager by defendant. This was properly the first issue addressed because defendant had initially provided a nurse case manager services effectively knowledge in that the services were reasonably required to cure or relief from the effects the injury. It was defendant’s obligation to prove that the nurse case manager services are no longer reasonably required. Defendant was required to meet that burden by the presentation substantial medical evidence.

3. The use of an expedited hearing to address medical treatment issues is expressly authorized by LC § 5502 (b) (1). The provision of nurse case manager services may be part of an employer’s medical treatment obligation under 4600. Therefore, it was proper for the WCJ to address defendant’s unilateral termination of nurse case manager services at the expedited hearing.

4. Is not necessary for an injured worker to obtain a request for authorization to challenge the unilateral termination of the services of a nurse case manager. Defendant acknowledged the reasonableness and necessity of the nurse case manager services when it authorize them. The applicant does not have the burden of proving their ongoing reasonableness and necessity. It is defendant’s burden to show that the continued provision of the services is no longer reasonably required because of a change in applicant’s condition or circumstances. Defendants cannot shift its burden onto the applicant by requiring new request for authorization and starting the process over again. All the evidence received at the hearing supports the continued provision of nurse case manager services. Defendants presented no evidence showing there has been a change in applicant’s condition or circumstances that contravenes its earlier determination authorizing nurse case manager services. Nor did defendant present any medical opinion or evidence showing that the continued use of the nurse case manager is not reasonable medical treatment in this case. The report of the AME was substantial evidence on the issue of the need for nurse case manager. Applicant is no obligation to continuously show the use of nurse case manager’s reasonably medical treatment. Once defendant authorize nurse case manager services as reasonable medical treatment it became obligated to continue to provide these services until they are no longer reasonably required under 4600 to cure or relieve the effects of the injury. Like all medical treatment decisions, that determination must be based on substantial medical evidence. Defendants failed to meet there burden of proof of showing by substantial medical evidence that applicant’s conditions and circumstances changed in a way that would make further provision of nurse case manager service no longer reasonably medical treatment in this case.

This case appears to suggest that is not necessary for an injured worker to obtain a request for authorization and go through UR/IMR in order to challenge defendant’s unilateral termination of medical treatment, when there is no change in circumstances. The case seems to claim that this is a WCAB issue and not an UR/IMR issue. Even though this case applied only to a nurse case manager it extends to all medical treatment issues. The WCAB held that the defendant acknowledged the reasonableness and necessity of the nurse case manager services when it authorized them. The applicant does not have the burden of proving their ongoing reasonableness and necessity. It is defendant’s burden to show that the continued provision of the services is no longer reasonably required because of a change in the applicant’s condition or circumstances. The defendant cannot shift its burden onto the applicant by requiring new request for authorization and starting the process over again.

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