Denial of reimbursement for medically necessary surgery upheld

A Florida appellate court on Wednesday upheld a denial of a worker’s request for reimbursement for a medically necessary back surgery since he obtained the treatment without complying with the terms of his employer agreement.

Carlos Tejeda, a City of Hialeah firefighter, injured his back in an on-duty motor vehicle accident in December 2013. The city accepted liability for his injury, and covered medical treatment as part of an agreement that stipulated that the city would authorize further surgical intervention if the city’s designated doctor said it was necessary, according to documents in Tejeda v. City of Hialeah, filed in the First District Court of Appeals in Tallahassee.   

In June 2020, without an opinion from the city’s doctor on medical necessity, Mr. Tejeda underwent spinal fusion surgery with the doctor who was not authorized as a treating physician. Mr. Tejeda then filed a petition seeking payment of the surgery bill and copayments as medically necessary.

Following denial, a Judge of Compensation Claims found the surgery was medically necessary but ruled that the 2017 stipulation was binding and denied reimbursement.

Mr. Tejeda appealed, arguing the 2017 stipulation made this a reimbursement dispute subject to the jurisdiction of the Department of Financial Services, so the judge lacked subject matter jurisdiction over the reimbursement dispute.

The appeals court disagreed, stating that dispute did not meet the statutory definition of a reimbursement dispute because Mr. Tejeda was not a health care facility or care provider.

The court also said that the JCC had jurisdiction to interpret the meaning of the stipulation to determine the parties’ rights and responsibilities under state Workers’ Compensation Law, and that the judge did not err in so doing.

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