Employer might have to cover back surgery: Appeals court

Despite issues with state-mandated medical treatment guidelines, an employer may have to cover another back surgery for a woman injured working at a home improvement store in 2011, an appeals court in Louisiana ruled Wednesday.

Christine Gotreaux “felt her back crack” while moving a rack of plants at a Lowe’s store in Lafayette, Louisiana, as an employee of Quick Turn Merchandising. Although her employer initially denied the claim, the matter was litigated and ultimately resolved by a consent judgment, which stated that Ms. Gotreaux was injured in the course and scope of her employment, awarding her compensation and medical treatment, “to be provided pursuant” to medical treatment as stated in workers compensation code, according to documents in Christine Gotreaux, v. Quick Turn Merchandising, et al., filed in the Court of Appeal of Louisiana, Third Circuit in Lake Charles, Louisiana.

Over the last eight years, Ms. Gotreaux “has seen numerous physicians and has had multiple surgeries, including both lumbar and cervical spinal fusions” and there “have also been several additional disputes about payments and medical treatment since the original consent judgment.”

The current dispute and appeal arose from an authorization for a thoracic spinal fusion that was not preauthorized by a medical doctor, relying on the state’s medical treatment guidelines. A state workers’ compensation judge, noting “that the thoracic spine is not covered by the medical treatment guidelines,” found that state law requires the judge to look to other guidelines in determining the evaluation.

The judge, in ruling in favor of the employer wrote that a common standard, when applying other guidelines “is to prove by clear and convincing evidence that the medical director was incorrect in his determination of whether or not… the treatment was appropriate under the guidelines.”

An examining physician, in his deposition, “agreed that there was no instability” and, per court documents, the medical director “based his decision on the fact that there was no instability.” The judge found that it has not been shown “by clear and convincing evidence” that the medical director was wrong with regards to his denial of the surgery and therefore declined to authorize the surgery.

The appeals court agreed that the guidelines are not sufficient yet “found no manifest error” in the judge’s decision to overturn the finding that there was no instability. However, appeals court “further found that the (judge’s) decision to rely ‘solely on segmental instability to the exclusion of the four remaining criteria in the lumbar spinal fusion spinal guidelines’ to be in error” and remanded the case to the Office of Workers’ Compensation “to determine whether Plaintiff has presented clear and convincing evidence that the decision of the Medical Director was not in accordance with the lumbar spinal fusion guidelines, specifically the indicators set forth in” state law.