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Thread Title: URGENT Sandhagen- UR vs AME-spine surgery
Created On Friday February 13, 2009 12:05 PM


laesquire
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Friday February 13, 2009 12:05 PM

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SCENARIO:

1. Parties go to an Ortho AME. He says NO future surgeries particularly for lower back.

2. About 2 years later PTP says Applicant needs revision lower back surgery. UR says YES to surgery.

QUESTIONS:


1. Can the Defense send the matter back to AME to analyze need for SPINE surgery or are they legally bound by U.R?

2. Can the Defense object to UR approval? If yes, what is the timeline?


I have seen treatment denied by UR , then go to Panel QME/ AME by AA. Usual Sandhagen scenario. However, here we have gone to the AME .

3. So does UR approval trump an AME prior rejection on SPINE surgery?

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 Any posting herein is NOT legal advice. It also does NOT create and attorney-client- relationship.

Edited: Sunday March 01, 2009 at 9:05 PM by laesquire

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spreare
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Friday February 13, 2009 2:46 PM

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If the UR approved the medical treament request then this treatment is considered authorized and must be reimbursed. The Defense has nothing to stand on especially as the AME is two years old. It's not that UR trumps the AME, but that UR authorized treatment on behlaf of the carrier. presumably the UR determination was in writing an sent to the parties. Defense cannot weasle out of this one in the usual sleazy manners.

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steve appell
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Friday February 13, 2009 5:13 PM

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UR Reports do not address causation, and AME's generally do. We dont know the applicant's history in the past 2 years. Therefore, other factors may have caused the need for surgery. Consequently, more info is needed before the dark side is once again condemned & accused of "weasling in the usual sleazy manner."

-------------------------
 Steve

A government which robs Peter to pay Paul can always depend on the support of Paul.
- George Bernard Shaw

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gaiassoul1@yahoo.com
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Friday February 13, 2009 5:14 PM

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I do not necessarily agree to the opinon above.

If UR approves the surgery, that tells me that there has been a deterioration of the condition. The AME reporting at two years old is beyond stale.

So the next question is did you object to your UR finding in a timely fashion per LC 4062(b) and if so, have you scheduled an AME re-eval to comment on the issue.

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laesquire
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Friday February 13, 2009 5:42 PM

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I represent the Defense. What I am trying to figure out is if UR approves treatment does it trump the AME on treatment issues? Assume no subsequent injuries. Just a pure medical treatment issues AME vs subsequent U.R. I am setting another exam with AME. On a side note PTP is a bad surgeon with several med mal judgments. However, Applicant insists on this PTP.

-------------------------
 Any posting herein is NOT legal advice. It also does NOT create and attorney-client- relationship.

Edited: Sunday February 15, 2009 at 11:07 PM by laesquire

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laesquire
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Friday February 13, 2009 6:37 PM

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Bump.


-------------------------
 Any posting herein is NOT legal advice. It also does NOT create and attorney-client- relationship.

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spreare
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Friday February 13, 2009 10:29 PM

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I am no brain trust on the issue or in general but really what a UR certification means is simply that -- certification: that a procedure will be authorized for reimbursement per the OMFS and within the specified certification dates. There is nothing beyond that to the UR issue in such a case except the certification for those procedures. There have been cases of defense backtracking on certifications -- yet unless there is substantial or material change of facts such as fraud -- a certification is a certification and difficult for a carrier to contest.

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steelmanlaw
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Saturday February 14, 2009 10:11 PM

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It might be useful to read Sandhagen in its entirety, including the concurring opinion. Just follow the law. And no, UR does not bind the defendant who may still defer to the AME; read the opinion and also ﾧ 4610. This is not that complicated, but may be a dead-end for defendant if the Board is not persuaded by an AME who contradicts a UR certification, and then orders the treatment irrespective of the AME opinion that the surgery/treatment is not reasonable.

It is not the practice of law that is all that confusing; but pursuit of justice can be, whether you represent worker or employer.

But that's just me.

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Loislane
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Sunday February 15, 2009 9:56 AM

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LA,

Are you dealing with a 4062 SPINAL SURGERY issue, which would require a second opinion?? I would take a close look at 4062 et seq. Your AME opinion is too stale for you to rely on, and to claim genuine medical doubt that the IW may need the surgery. You may be leaving your client wide open for penalties on this.

I believe 4062 is instructive here. Additionally, i do not know what the interplay would be with your AME and a mandatory second opinion on spinal surgery.

Jake or James?

Lois

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inquiring mind
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Tuesday February 17, 2009 11:26 AM

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I don't get this. Is your client asking you to object to their own UR decision? Knowing how difficult it is for a UR company to authorize something, I would think that this particular UR company has all the necessary information to authorize the surgery. There is time limitation involved in invoking LC 4062(b). A few years ago, an en banc decision came down dealing with LC 4062(b).. Check the web site of WCAB to read.

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Jpod
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Tuesday February 17, 2009 1:21 PM

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I will attempt to answer based on your follow up posts.

If there is no other issue then if the treatment plan, which calls for a surgical revision, is compliant with ACOEM or some other guideline then I think the answer is the AME has no place since the treatment plan appears to be consistent with ACOEM. That is all a UR cert says. If UR approves the treatment plan the employer does not get to go to a QME/AME over that issue, only the applicant - isn't that what Sandhagen said?

But, as Steve points out, if there are other issues that are applicant or case specific and have nothing to do with ACOEM (e.g. prior AME in pysche says no more surgeries b/c applicant is a malingerer or drug seeking, or employee's need for surgery revision is due to new employment or a host of other questions that ACOEM and UR have no place discussing) then you have issues outside of UR that might require the need to return to the AME.

Without knowing more it is really hard to say anything else. A 2 year old report is stale as it pertians to most issues but not necessarily all, such as a history of drug seeking or Munchausen syndrome.


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OuttaTime
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Tuesday February 17, 2009 3:59 PM

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Doesn't Simmons v California (2005) 70 CCC 866 apply here?

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errgal
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Wednesday February 18, 2009 10:20 AM

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To take this question up a notch, what if the UR authorizes surgery while an AME report is pending? Report comes back 20 days after UR auth, but states surgery not reasonable? Can the "certification/authorization" be revoked? I woudn't think that it is appropriate or helpful to delay all UR determinations until AME eval is completed and report recieved, but on the other hand if there is no recourse from the above situation, it would appear to be the only result. Thoughts?

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rider001
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Wednesday February 18, 2009 11:57 AM

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I would think that it would hinge upon a timely obejction to the surgery and the results of the second opnion.

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laesquire
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Sunday March 01, 2009 8:59 PM

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Good information here.

Clarification of my prior post: UR approves SPINE surgery , yet defendant wants to dispute it and send it back to the AME for further comment.


My limited understanding of Sandhagen as decided by the California Supreme court:

1. If Utilization Review certifies a medical procedure / test ( like MRI etc.) , then Defendant has to authorize( absent a defense like the treatment needed is caused by something else like a subsequent auto accident , not part of the work injury claim etc.) it. Defendant does NOT go Panel QME or AME.


2. If UR does NOT certify treatment then Applicant can try medical -legal objection process like AME, Panel QME etc.


This is where I get confuesed. Labor Code 4610 UR seems to imply allowing other methods to resolve SPINE SURGERY issues.
Because 4062(b) is it's own section. So if Defendant does NOT like UR decision authorizing SPINE SURGERY they can go 4062(b) SPINE SURGERY panel or prior selected AME.


-------------------------
 Any posting herein is NOT legal advice. It also does NOT create and attorney-client- relationship.

Edited: Sunday March 01, 2009 at 9:08 PM by laesquire

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STEVEPSCA@YAHOO.COM
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Monday March 02, 2009 8:53 AM

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There is a 'new member' addressing this issue "SSSOP'...


<< Spinal surgery requests are controlled by the SSSOP [spinal surgery second opinion procedure]. This was explained in the WCAB significant panel decision Brasher v Nationwide Studio Fund (2006) 71 CCC 1282, which was recently followed in the panel decision Baldridge v. Vons 2008 Cal. Wrk. Comp. P.D. LEXIS --- >>

The post is available in the UR, MPN ...topics here...http://www.workcompforums.com/ca/pro/messageview.cfm?catid=19&threadid=5111


But I have a question... Doesn't the "SSSOP" med/legal evaluator have to be a AME/PQME who has NOT previously been involved in this claim, and have no relationship to the parties/claim ?

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