Court: Louisiana Court of Appeal; September 30, 2015; Louisiana; State Appellate Court
Marsala Beverage Company and its insurer, LUBA Casualty Insurance Company, appeal a workers’ compensation judge's decision that reversed the denial of medical treatment for plaintiff James Arness Thomas. Thomas, a forklift operator, was injured on November 4, 2010, when he fell from a delivery truck during loading operations. The incident is recognized as work-related, resulting in injuries to his neck, back, arms, and wrists. Marsala acknowledges Thomas's temporary disability and has provided some compensation and medical benefits.
Initial treatment was provided by Dr. Ronald Woods, followed by an MRI that showed no herniated disc. Thomas was referred to orthopedic specialist Dr. Douglas C. Brown, who conducted further MRIs and treatments, including injections that offered temporary relief. LUBA denied coverage for additional injections and treatment, including physical therapy, which was halted due to Thomas's high blood pressure and swelling.
By August 2011, neurosurgeon Dr. Marco Ramos diagnosed Thomas with cervical and lumbosacral radiculopathy, median nerve entrapment, and vascular issues. In January 2013, Dr. Ramos noted signs of cervical strain and recommended further physical therapy, which was again terminated due to increased pain. By June 2013, Thomas was diagnosed with carpal tunnel syndrome, and although surgery was recommended, LUBA refused to cover it, claiming the condition was unrelated to the workplace accident.
Throughout this period, LUBA referred Thomas to Dr. Donald Smith for impairment evaluations. Dr. Smith found normal spinal examinations and imaging but noted Thomas's restricted range of motion and poor prognosis for returning to work at Marsala, while suggesting he could engage in various activities without restrictions. Thomas later consulted Dr. Eric Oberlander, who deemed a prior MRI of poor quality and recommended a new examination by a different radiologist.
An MRI conducted in August 2013 revealed spondylosis and stenosis at multiple lumbar spine levels, with a concentric bulge at L5-S1. Dr. Oberlander deemed Thomas ineligible for surgery and referred him to neurologist Dr. Benjamin G. Kidder, then to anesthesiologist Dr. Vincent R. Forte for pain management. Although LUBA initially resisted this referral, they later approved it after Thomas filed a disputed compensation claim in November 2013. Thomas began treatment with Dr. Forte in January 2014, reporting pain across various areas and exhibiting limited range of motion in his spine. Dr. Forte administered lumbar medial branch block injections on January 30 and February 6, resulting in 50% and 25% pain improvements, respectively. However, by February 20, Thomas expressed dissatisfaction with the relief from the injections, although he rated his pain at a low level. Dr. Forte recommended an epidural steroid injection (ESI) at L5-S1, but LUBA denied coverage on February 24, citing a prior assessment by Dr. Donald Smith, who did not recommend further injections or therapy.
The denial was appealed to the Medical Director with the OWC, who reviewed the case under Louisiana Workers’ Compensation Medical Treatment Guidelines. On March 6, 2014, Dr. Roy M. Lee denied the ESI, categorizing it as diagnostic and not permissible under the guidelines. Thomas sought judicial review, leading to a hearing on April 28, 2014, where his medical records and Dr. Forte’s deposition were admitted as evidence. The WCJ reviewed the arguments from both sides and, on July 17, 2014, found that the AMD's decision was not aligned with La. R.S. 23:1203.1 provisions. Consequently, a judgment reversing the AMD's denial was signed on August 12, 2014. Marsala and LUBA appealed, claiming the WCJ erred in her ruling, but their argument was deemed without merit.
A workers' compensation claimant in Louisiana is entitled to recover costs for medical treatment that is reasonably necessary for conditions caused by work injuries, as per La. R.S. 23:1203(A). The 2009 enactment of La. R.S. 23:1203.1 aimed to create guidelines for treating injured workers, ensuring efficient and timely delivery of medical services. Medical necessity includes treatments aligned with the Medical Treatment Guidelines (MTG) and clinically appropriate for the patient’s condition, rather than for convenience. Variances from the MTG are permissible if proven necessary by scientific medical evidence. The law mandates that after a medical provider submits a treatment authorization request, the payor must respond within five business days. Disputes regarding treatment conformity to the MTG should be appealed to the workers’ compensation administration within fifteen days, with a decision expected within thirty days. Further appeals can be made using the Disputed Claim for Compensation form if the initial decision is contested, requiring clear and convincing evidence to overturn the medical director's decision.
Prior to La. R.S. 23:1203.1, insurers determined appropriate medical treatments, with disputes resolved by Workers' Compensation Judges (WCJs) using a preponderance of the evidence standard. The new law requires claimants appealing a Medical Director's decision to prove medical necessity by clear and convincing evidence, while the initial burden before the Medical Director remains a preponderance of the evidence. The clear and convincing standard is intermediate, requiring a demonstration that a disputed fact is highly probable. WCJ factual findings are reviewed under the manifest error or clearly wrong standard, necessitating a two-part inquiry for appellate reversal: establishing a lack of reasonable factual basis and determining the finding is clearly wrong.
In this case, the Administrative Medical Director (AMD) found the requested epidural steroid injections (ESIs) were not medically necessary, citing a lack of correlation between clinical findings, disease history, and diagnostic tests. The AMD identified three reasons for this conclusion: non-compliance with the medical treatment schedule, insufficient correlation between the alleged disease and treatment, and unclear documentation regarding the source of the claimant’s pain. The AMD highlighted that the medical treatment guidelines accept only specific injection types for diagnosing spinal issues and noted a lack of strong clinical evidence indicating a pathological condition. An MRI showed no significant nerve root compromise, and the AMD indicated that there was no documentation supporting the proposed procedure as a means to facilitate active therapy.
Diagnostic spinal injections are recognized as established procedures useful for pinpointing pain sources and can have therapeutic benefits when combined with medications. However, they carry inherent risks, necessitating a careful evaluation of the risk-benefit ratio. Prior to these invasive procedures, less invasive options should be explored. Patient selection and the specific injection site should be guided by clinical indications of potential pathology. The number of diagnostic injections should be limited to those most likely to reveal primary pain generators, avoiding unnecessary procedures aimed at identifying every possible pain source.
Test results from these injections are interpreted based on functional changes, symptom reports, and pain responses measured on recognized pain scales. The diagnostic significance should be assessed alongside clinical information and results from other tests. Accurate documentation of patient responses immediately after the procedure is essential, including symptom details and hourly logs of responses for at least the anesthetic duration. Practitioners must specify the local anesthetic used and its expected duration.
Multiple injections in a single session may diminish the diagnostic value, prompting practitioners to balance diagnostic and therapeutic benefits carefully. Therapeutic spinal injections are recommended following unsuccessful conservative treatments and should only occur after imaging and diagnostic injections confirm a pathological condition. Given their invasive nature, these injections require strict adherence to clinical indications and contraindications. They are intended to provide temporary relief and should be accompanied by ongoing active rehabilitation efforts, as injections alone are unlikely to yield long-term benefits.
Subjective pain reports, assessed through a recognized pain scale, should be given consideration alongside objective anatomical findings when evaluating pain responses. Epidural Steroid Injections (ESI) involve administering corticosteroids into the epidural space to alleviate pain and inflammation, thus promoting rehabilitation. There are three ESI approaches: transforaminal/spinal selective nerve block (preferred for unilateral issues), interlaminar (best for multi-level pathology), and caudal (less precise). The Workers' Compensation Judge (WCJ) reviewed over three years of medical records and determined that the denial of ESI by LUBA and the AMD was unfounded. Dr. Forte diagnosed Thomas with lumbar facet joint syndrome and recommended ESI after prior treatments, including lumbar medial branch blocks, provided limited relief. An MRI revealed a disc bulge at L5-S1, correlating with Thomas's pain. The WCJ concluded that the ESI was necessary for pain relief rather than merely diagnostic, supported by medical evidence and testimony indicating the pain's source was indeed at L5-S1. The WCJ's ruling to overturn AMD's decision was deemed appropriate and justified based on clear evidence of medical necessity for the ESI.
The decision of the Office of Workers’ Compensation in favor of plaintiff James Arness Thomas is affirmed, mandating that defendants Marsala Beverage Company and LUBA Casualty Insurance Company provide the ESI treatment recommended by Dr. Vincent Forte. The costs of the appeal are assigned to the defendants. Notably, there has been a delay of over 18 months from the initial treatment request to the issuance of this opinion, raising questions about efficiency and timeliness. The Administrative Medical Director (AMD) lacked Dr. Forte's deposition, which was taken shortly before the Workers' Compensation Judge (WCJ) hearing. Under current jurisprudence, the WCJ may consider new evidence not presented to the AMD. Dr. Forte's deposition offered a clear rationale for the medical necessity of the ESI treatment, which the WCJ endorsed, aligning with the pain management physician's views.
