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Thread Title: Need A Labor Code
Created On Sunday February 08, 2009 10:34 AM

injuredworker101@yahoo.com
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Sunday February 08, 2009 10:34 AM

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Does anyone know the specific labor code which states:

If a non industrial condition, must be cared for, before an industrial related surgery can take place, that the insurance co is liable for that treatment?

I've been searching the labor codes and it is like fishing in a giant ocean.

Thanking You in advance IW101

Loislane
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Sunday February 08, 2009 11:26 AM

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IW,

Here is a previous post that deals with this subject.

If you use the SEARCH fn with the word "BRAEWOOD" you will get a wealth of info. Additionally, the BRAEWOOD case was a CA Sup Ct case. Keep in mind, however, that UR and ACOEM WILL APPLY.

What are you trying to get treated in order to treat the industrial condition?

"If an IW has an underlying medical condition that has to be treated dealt with in order to cure or relieve the industrial injury, then the IC is LIABLE for tx to that condition. The seminal case that addresses this is a CA Sup Ct case, Braewood Convalescent Hospital. In this case, (If memory serves me correctly) an IW was mordibly obese. The IW has a knee injury that needed to be surgically corrected. However, the obesity needed to be addressed medically, prior to the knee. The IW was awarded a weight loss program. This is based on the WC tenets that med tx is not apportionable. However, Art BE PREPARED FOR A FIGHT. DA's fight this crap tooth and nail."

http://www.workcompforums.com/ca/iw/messageview.cfm?catid=10&threadid=2794&highlight_key=y&keyword1=Braewood

Lois

injuredworker101@yahoo.com
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Sunday February 08, 2009 3:19 PM

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Ok...thanks!

No wonder I couldn't find the labor code; it is case law!

Here's the situation:

I showed up for an industrial surgery, but got sent home because I was taking antibotics for a urtherial infection. The urtherial infection is not work comp.

The doctor said to clear the infection and then return to him.

I went to the urologist (non industrial) who now wants to do an outpatient procedure to see where this problem is coming from because it looks like this is a chronic condition. I must add that the initial time I first had this infection goes back to 87.

So its either out of pocket for me (60/40 split); or, the insurance co picks this up. That is, if the orthopaedic doctor, who is work comp, doesn't want to operate until this is resolved.

Therefore, what I was looking for was the arguement to present that this payment should be picked up by the insurance co should I so need.

Thanks

injuredworker101@yahoo.com
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Sunday February 08, 2009 3:22 PM

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P.S. Thanks for the link. I did read it.

I also went over to Lexis/Nexis and printed out the copy of the case law. Is that all I need? Braewood?

postscript2
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Sunday February 08, 2009 3:57 PM

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Hi 101:

While it is true that you are still not MMI or P&S, it varies as to what the I/C will or will not pay for.

TTD-YES. Treatment per Braewood is vastly different than what you described.

It doesn't sound like it is causily related to your injury; in other words, the weight gain in the aformentioned case is something that had to be achieved before an operation could be successful. However, I've had many cases similar to yours.

Take pregnancy for instance... Did the ER/defense pay for all of the Gyno tx and delivery of the baby, prior to the surgery taking place--Answer is definately NO...

If you developed your current illness as a result of say, medications due to your injury, then I would answer YES-I/C should pick it up. But in reality-it's on the far side.

I wish you all the best! Don't try to figure this all out on your own... Seek the advise of counsel.

Take care,

LCS

Loislane
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Sunday February 08, 2009 9:41 PM

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101,

I am with PS, here.

My educated guess is it won't be compensable. And, here is why: It sounds like your Dr is interested in WHERE the infection is coming from/what is the cause?. The IC DOES NOT GIVE A RAT'S ASS

WHERE your infection is coming from, what the cause is, they only want to give you cranberry juice and a couple of pills in the hopes it clears up for your surgery.

Good analogy with the pregnancy, PS. Never having been on your side of the fence in the business, it is good to get a well balanced view. I always appreciate your input.

Hope this helps.

Lois

injuredworker101@yahoo.com
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Monday February 09, 2009 10:42 AM

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So here's a hypothetical:

Why is a person with diabeties or hypertension that's out of control allowed to have WC pick it up prior to surgery? Is there any case law on this? Because, I know of cases where this has happened.

With pregnancy this is not considered a disease. I remember that was an arguement way back with SDI.

Of interesting note:

Cranberry juice is actually the wrong thing to use for any bladder or urethrial infection so I learned from this urologist. Cranberry juice is only for kidney infections. It yields too much acididy to the bladder lower parts and irritates rather than cures. This was a new one for me because I was drinking this stuff for that thought reason. Additionally, vitamin C does the same with the lower UT.

Loislane
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Monday February 09, 2009 11:42 AM

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CA. SDI does cover pregnancy.

As far as cranberry juice, you should suggest that your Dr does a basic Google search.

The National Kidney and Urologic Diseases Information Clearinghouse, states that cranberry juice is efficacious for UTI's. This is, in part, what they suggest:

"How can I prevent more UTIs?
Changing some of your daily habits may help you avoid UTIs.

Drink lots of fluid to flush the bacteria from your system. Water is best. Try for 6 to 8 glasses a day.

Drink cranberry juice or take vitamin C. Both increase the acid in your urine so bacteria cant grow easily. Cranberry juice also makes your bladder wall slippery, so bacteria cant stick to it."

Here is a link for their info. You can find many Peer Reviewed Journal acticles on the subject.

http://kidney.niddk.nih.gov/Kudiseases/pubs/uti_ez/index.htm

As far as hypertension and diabetes, if these are not controlled and a patient were to have a surgical procedure, they could die.......
Wish i could offer you more suggestions.

Sorry.

Lois

Edited: Monday February 09, 2009 at 11:43 AM by Loislane

injuredworker101@yahoo.com
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Monday February 09, 2009 2:15 PM

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Thanks for the help.

I guess I should have stated that SDI came upon not a "disability" until the final phases, unless it were a problem preg. Long ago, this was hashed over and I left that out.

I think, in my case, there is more to this in my situation, the doctor says no to cranberry etc, just because the acidic climate is in fact making the situation worse ie blood in the urine. I was told however that cranberry was for kidney straight from that particular doctor. That surprised me too.

Anyway, thanks...I'll wait and see what my doctor says then follow his plan re the orthopaedic surgery.

postscript2
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Monday February 09, 2009 4:00 PM

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Hi 101:

I hope you feel better soon!

I can't give you a labor code per se, as many of them are or can be overturned by "case law." Additionally, most labor codes are "regulated" by the California Code of Regulations, otherwise referred to as the "CCR's." This tells us how to "apply" the labor codes. I only write this because if anyone is unfamiliar with how it works, it will frustrate the heck out of you! Very few codes "stand" alone. In other words, one bounces off of another, over and over again-- kind of like your anology of it being a huge ocean; consider the "waves" of other labor codes in addition to the CCR's and it may be like being on the Titanic with no life raft...

Back to your question re the urethra infection--I doubt the I/C will pay for the tx.

Even if it's not something that's initially serious, then once an I/C opens the door, it "could" be construed that the I/C auth the initial tx and be held liable for any and all complications thereof that could have arisen from a "non-industrial" injury, unrelated to your claim. This is a very risky situation for the I/C and C/A. Let's say (and I hope it's not your situation), that a simple UTI turned into a kidney infection. The kidney infection doesn't clear up and soon stronger meds are needed and so on. Then the C/A decides--"not their problem..." Well first, they have established that they have overriden U.R. and if taken to court, "could" be held liable for making "medical" decisions by overriding the "dreaded" U.R.--And be on the hook for any and all complications arising out of this unfortunate situation.

I've seen this happen over and over and over again. This is why you are being met with resistance for providing treatment for your current medical problem. Now "pre-existing" disease, such as diabetes and heart conditions are usually known very early on in a claim and it goes without saying that surgery is a huge risk for these I/W's and the complications that can arise. Thus the I/C must pay to cure the "underlying" disease or condition, to a point, where the I/W is "stable" enough to undergo surgery. And ghast and God forbid, if an I/W contracts an infection "as a result" of a procedure and surgery, then that is a "compensable consequence" and would have to be covered.

In your case, if you had chronic and "pre-existing" kidney problems prior to your industrial w/c injury, then that would likely qualify as a "pre-existing" disease/condition, similar to diabetes, etc.

I'm certainly not making light of your situation and I dearly feel for you. I of course can't give out "legal" advise, due to the obvious, but what I can do is try to shed some light on why things happen in w/c and the possible reason thereof.

Many EE's have pre-existing conditions in the workforce. If the ER's refused to hire them, it would likely eliminate as much as 1/4 of the workforce, in my best estimate. Thus the premise, that the ER hires an employee "as is" (don't mean to sound harsh) and if they discriminate, well--that's another subject and subject to heavy civil sanctions.

I do hope you get the treatment you need--personally, and it's just my opinion, I don't think that your TTD should be stopped. Those are aweful infections and quite painful, so Godspeed!!!

Take care and God Bless,

LCS

Edited: Monday February 09, 2009 at 4:15 PM by postscript2

injuredworker101@yahoo.com
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Monday February 09, 2009 8:09 PM

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Thanks P.S.:

Actually, maybe it was missed in my postings but this was initially diagnosed in 1987 when I was going to college. My Date of Injury is... gasp...2000. The delay is due to much litigation. The claim has never been settled just litigated like crazy. (Not on my part)

Any input on this has, and is appreciated.

STEVEPSCA@YAHOO.COM
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Tuesday February 10, 2009 5:36 AM

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'Why is a person with diabeties or hypertension that's out of control allowed to have WC pick it up prior to surgery? Is there any case law on this? Because, I know of cases where this has happened.'

One, every claim is different, and the underlying factors are obviously 'different'. There is no way to lump sum 'compensable consequence' into one pot.

Two... your condition being diagnosed in 1987 is an ongoing condition that you deal with periodically on your own with your own physican.
Your claim is 2000 and due to the litigation process, your ortho surgery has been postponed...more than one as I recall.
The basis now is, IS your condition necessary to be treated prior to the surgery, on an 'industrial basis'...?
Maybe, maybe not, you've waited 8+ years for this operation... a few weeks/month is unlikely to make a difference. (?)

So... your question is going to be based on "medical necessity' and 'reasonableness' on the industrial basis. That will be to ACOEM/MTUS/EBM guidelines... and must be substantiated by your PTP in the request for treatment.
No doubt the CA will submit to UR for the determination, you/PTP will appeal...timely, and a PQME will be used to resolve the issue.

As your claim/DOI is 2000, and you've used the 'dueling QME's' and/or AME process before for disputed medical issues... that will be the process for this issue as well.

So hashing this out between the IW'/Pros here is unlikely to provide a definitive answer.
Take it to the 'judge'....(though the med/legal process of course.... as you know, that is in LC 4062 and the CCRs)

May as well begin here...'ﾧ9792.9. Utilization Review Standards--Timeframe, Procedures and Notice Content'...http://www.dir.ca.gov/t8/9792_9.html

Here are the 'Article 4. Evaluation Procedures' (PQME/AME's) http://www.dir.ca.gov/t8/ch1a4.html

Here is the MTUS guidelines http://search.ca.gov/search?q=cache:jVmjRuJpCZUJ:www.dir.ca.gov/dwc/DWCPropRegs/MTUS_Regulations/MTUS_Regulations.pdf+%20%20%20%20title+8+physical+therapy&oe=UTF-8&proxystylesheet=xfix&output=xml_no_dtd&client=xfix (dont know if these will help you or not.)

injuredworker101@yahoo.com
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Tuesday February 10, 2009 9:27 AM

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Thanks Steve,

I have been "poking around in the dark" in order to figure out how to handle this when I see my doctor. The comments given have been most helpful.

In all fairness, I should add that I haven't been able to really spread out all the fine details going on, because this is a public forum. So those answers of which I am getting are at least pointing me in some direction.

Thanks to everyone who's helped.

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