The client, a certified nursing assistant, experienced a compensable work
accident when she injured her low back while transferring a client from
a wheelchair to a bed. The accident was not contested by the insurance company.
Diagnostic testing confirmed a disk herniation at L4-5 and moderate pathology
at L5-S1. After undergoing over one year of unsuccessful conservative
medical treatment (physical therapy, prescription medications, and epidural
injections), the client selected a new treating physician from the employer’s
posted panel. The parties subsequently filed a change of physician form
with the State Board of Workers’ Compensation.
The new treating physician ultimately concluded the client was a surgical
candidate. Unfortunately, the insurance company refused to authorize surgery.
Instead, the insurance company sent the client for an independent medical
examination (IME). The IME physician did not dispute the need for surgery,
but questioned the type of surgery prescribed for the claimant. Nonetheless,
the insurance company still refused to authorize the recommended surgery
by the treating physician.
At the hearing, the administrative law judge (ALJ) was not happy with the
insurance company’s delay in this claim. The ALJ authorized the
surgery and placed substantial emphasis on the treating physician’s
opinion. The ALJ also referenced the IME opinion wherein that physician
never stated surgery was not necessary. Most importantly, the ALJ assessed
attorney’s fees against the insurance company in excess of $4,000
because it failed to provide any medical evidence to suggest that the
surgical recommendation was inappropriate. Contrary to the insurance company’s
assertion, and as determined by the ALJ, the surgery issue was not closely
Recognizing its absurd position, the insurance company properly abandoned
any further attempts to deny surgery following the ALJ’s decision.
The client recently underwent back surgery and is currently rehabilitating
in an effort to resume gainful employment.