How To Determine Whether Medical Treatment Is Reasonable And Necessary

The case that is discussed in this issue is not certified for publication.  However, you can use the material within the opinion that does refer to citeable cases; the case deals with determining if self-procured medical treatment is reasonable and necessary.

The applicant had an admitted injury. The case was resolved-by stipulations with Request for Award.  There was an unresolved lien of $39,545.00 for self procured medical treatment. In the Stipulation it was included that the defendant would pay or adjust the self-procured treatment. The Editor of this newsletter does not recommend that this be done: You should state that you will pay, adjust or litigate. Without saying- the word litigate you are saying you must pay something. Therefore, there-probably should have been a penalty issue in this case since the defendant did not pay. The defendant also held the applicant harmless and the editor would not recommend that you do this either.

The lien was tried before a Workers Compensation Judge (WCJ). The WCJ disallowed the lien on the basis that the applicant stated that the treatment was of very little benefit.

The appellate court reviewed the criteria for deciding what is reasonable and necessary to cure and relieve from the effects of an industrial injury. The court reviewed many citeable cases to make their- determination.

Once the employee selects the primary treating doctor the employer acquiesces in the treatment that physician provides.  Whether the physician can recover for performing that treatment is not determined by whether the treatment was successful.  Many times the treatment will not have a lasting effect. It can still be reimbursable. Treatment that even has no effect can even be reimbursable.

The question becomes whether the treatment that was prescribed was reasonable in light of the applicant’s injuries. Just because treatment, did not cure the applicant is not deterrninative.

In order to prepare for arguing whether self-procured was reasonable and necessary the defendant should take a deposition in which they determine all the treatment that was given over what period of time, and how beneficial this was. The defendant should then send this information, to a physician pursuant to the rules to determine if the self-procured treating doctor has prescribed the correct course of treatment.

Case: Interventional Pain Management V. WCAB (Stratton)

Harvey Brown
3501 Jamboree Rd. Suite 602
Newport Beach, CA 92660

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