In the event of an injury in the workplace, it can be difficult to know what options for medical treatment are available to you that are covered under workers’ compensation. This is troubling if you are currently receiving treatment that is not adequately treating your condition and you would like to seek treatment that your doctor has not recommended. The Alabama Court of Civil Appeals addressed a case like this in Ex parte Trusswalk, Inc., from Marshall County, Alabama. The Court addressed whether an employer can be compelled to authorize pain-management treatment without a recommendation by a medical professional.
Chesley Price (“employee”) sought workers’ compensation because of a lower back injury that allegedly occurred in a work-related accident. Because he was still experiencing severe back pain after multiple surgeries, the employee filed a motion to require Trusswalk, Inc. (“employer”) to refer the employee to pain-management services. The trial court, after holding a hearing, ordered the employer to refer the employee to pain-management services. The employer appealed the decision.
Under Code of Alabama, 1975, Section 25-5-77(a), an employer is required to pay for medical treatment that is “reasonably necessary.” Medically necessary treatments are consistent with the diagnosis and treatment of the diagnosis, satisfy the standard of care for good medical practice, cannot only be for convenience, be the most appropriate or cost-effective option based on the patient’s condition, and have medical value established scientifically. An employee may show that a medical treatment is “reasonably necessary” based on the opinion of a medical expert or because the necessity can be inferred based on circumstantial evidence.
Because the employee did not seek the opinion of a medical expert saying that pain-management services were reasonably necessary, he argued that the necessity of pain-management services may be inferred based on his condition. In doing so, the employee provided medical records showing that he underwent five surgeries for his back injury with multiple doctors and that he was assigned permanent physical restrictions by his last surgeon.
The Court stated that, while necessity may be inferred based on the circumstances for some treatments, the necessity of other treatments may only be shown with expert opinion when a lay person could not infer that a treatment is medically necessary. The Court looked to state regulations addressing pain-management services to determine whether this form of treatment is the sort that a lay person would understand enough to infer when it is necessary. In finding that these services are beyond what a lay person could infer necessary, the Court identifies that pain-management services are to be provided by specialists registered with the Alabama Board of Medical Examiners, that these services involve dispensing controlled substances and other forms of treatment, and that pain-management services must be pre-certified, or assessed to be medically necessary and appropriate, before they may be provided.
The trial court could not infer that pain-management services were reasonably necessary. The Appellate Court vacated the lower court’s order for the employer to refer the employee to a pain-management specialist. In doing so, the Appellate Court held that this decision does nothing to prevent the employee from obtaining pain-management services going forward nor does the decision prevent the employee from obtaining the opinion of a medical professional that pain-management services are necessary for his condition.