What Can You Do When the Insurance Company Will Not Authorize the Recommended Medical Care?

By: Boffeli & Spannagel, P.C. Workers’ Compensation Attorneys

Under Iowa workers’ compensation law, the insurance company and employer cannot interfere with the medical judgment of their own treating physician. Schwers v. Nordstrom Distribution Center is a December 17, 2018 Alternate Medical Care Decision from the Workers’ Compensation Commissioner that deals with this rule.

In the Schwers case, the injured worker, referred to as a “Claimant”, had injured her back on August 10, 2017 while working for Nordstrom Distribution Center. Nordstrom is self-insured for work comp injuries which means it pays the medical care and work comp benefits itself. Nordstrom accepted the injury and provided medical care. Dr. Michael Chapman was authorized by Nordstrom to provide medical care. Dr. Chapman performed a low back fusion surgery on the Claimant.

Unfortunately, the Claimant continued to have low back pain. Dr. Chapman referred the Claimant to pain doctor #1 who performed a number of tests and a diagnostic medial branch block. Pain doctor #1 gave the opinion that a medial branch problem and facet disease could be ruled out as a cause of the Claimant’s back pain. The Claimant returned to Dr. Chapman who sent the Claimant back to pain doctor #1 for consideration of a spinal cord stimulator trial. The pain doctor #1 recommended against the spinal stimulator option and instead, recommended conservative treatment.

In response, Dr. Chapman referred the Claimant to pain doctor #2 for evaluation for a Nevro spinal cord stimulator trial. However, Nordstrom argued that pain doctor #1 had recommended against a spinal cord stimulator and refused to authorize the referral to pain doctor #2.

The Claimant filed a Petition for Alternate Medical Care that came on for hearing on December 17, 2018. An Alternate Medical Care hearing provides an injured worker the chance to argue they should receive medical care that has previously been refused. A decision is then made by the Deputy Workers’ Compensation Commissioner, who acts as a sort of judge in workers’ compensation cases. At the alternate medical care hearing, the Claimant argued that pain doctor #1 did not work with the Nevro brand spinal cord stimulator, and therefore the referral to pain doctor #2 who regularly used the Nevro brand spinal cord stimulators was reasonable.

The Deputy Workers’ Compensation Commissioner that heard the case, ruled in favor of the Claimant and ordered the employer to authorize a referral to pain doctor #2 to determine whether the injured worker could benefit from a Nevro spinal cord stimulator trial. The Deputy Commissioner’s reasoning was:

1. An employer is required to furnish reasonable medical care for work injuries.
2. The employer generally has the right to choose the provider of the medical care, but the treatment must be offered promptly and be reasonably suited to treat the injury without undue convenience to the injured worker. If the injured worker is dissatisfied with the care, the worker can file a Petition for Alternate Medical Care.
3. The injured worker bears the burden of proving that the care authorized by the employer or insurance company is unreasonable. The care authorized by the employer/insurance company is unreasonable if it is ineffective, inferior, or less extensive than the care requested by the employee. The determination of whether care is reasonable is a question of fact for the Workers’ Compensation Commissioner.
4. The referral was made by the authorized medical care provider. The employer cannot interfere with the medical judgment of its own authorized treating physician.
5. In this case it was reasonable for Dr. Chapman to make referrals to two different pain doctors to determine whether a spinal cord stimulator trial could help the Claimant.