Court Emphasizes Authorized Treating Physicians Must Precertify Pain-Management Treatment as Reasonably Necessary for Workers’ Comp Claims
Ex parte Trusswalk, Inc.
In
Ex parte Trusswalk
,
Inc.,
the employee (“the Plaintiff”) filed a workers’ compensation action against his employer (“the Defendant”) in the Madison County Circuit Court alleging that he had suffered a lower-back injury in a work-related accident. Approximately six months after the Plaintiff filed the workers’ compensation action, he filed a “motion to compel medical treatment” requesting the circuit court order the Defendant to provide “appropriate medical treatment” for his back.
In the Plaintiff’s motion, he claimed that his authorized treating physician was not treating the “chronic-debilitating pain” in his lower back and that the Defendant denied his request for referral to pain management. To prove his need for pain-management services, the Plaintiff submitted medical records to the circuit court showing that he had undergone five surgeries to treat his back. However, the Defendant argued that the motion should be denied because the Plaintiff's authorized treating physician had not referred him for pain management and the medical records contained no express referral. Ultimately, the circuit court ordered the Defendant to immediately refer the Plaintiff to a pain management specialist. The Defendant filed a petition for a writ of mandamus with the Alabama Court of Civil Appeals.
The threshold issue on appeal was whether the circuit court abused its discretion by ordering the Defendant to provide medical treatment, which the Plaintiff’s authorized treating physician never recommended. The Defendant maintained that the circuit court could not award the Plaintiff his requested relief absent a physician’s referral to a pain management specialist or without a medical opinion that such treatment was reasonably necessary. The Court of Civil Appeals agreed. In its opinion, the Court emphasized that expert medical testimony is required in some cases to establish the reasonable necessity of medical treatment when a lay person could not readily infer such a need from circumstantial evidence alone, one of which is pain-management treatment.
The Court also noted that the Department of Labor has issued a regulation which provides that pain-management services
must be precertified
as reasonably necessary before those services can be provided to an injured employee through a workers’ compensation program. Ala. Admin. Code, Rule 480-5-5-.08(2)(i) (emphasis added). Because the Plaintiff’s medical records did not contain enough information from which the circuit court could infer that such specialized treatment was reasonably necessary, the Court held that a medical expert should have made the determination whether the Plaintiff required pain-management treatment. Thus, the Court directed that the circuit court vacate its order.
