Court of Appeals Awards Alternate Medical Care in Denied Liability Case

 West Central Cooperative v. Sullivan, No. 21-1559 (Iowa App. Aug. 31, 2022)

In the original administrative action in this case, claimant, who had an injury in 2011, sought authorization for a spinal cord stimulator, which had been recommended by an authorized treating physician.  A DME physician, Dr. Chen, opined that the continuing back problems of claimant were not causally related to his work activities.  Claimant filed for alternate medical care and the action was dismissed under section 85.27 and 876 Iowa Administrative Code 4.48 because of defendants' denial of liability.  Claimant asked for rehearing, arguing that the issue of liability had already been established in the initial administrative proceeding.  This request was denied. 

A contested case proceeding was initiated by claimant, who argued that the continuing back problems were related to the work injury and further alleged that he was entitled to the SCS trial.  The deputy found that the SCS trial was not reasonable and further found that Dr. Chen had authorized a reasonable course of treatment.  On rehearing, the deputy concluded that the cause of the back pain did not need to be established as the SCS trial was not necessary.  On appeal, the commissioner addressed the causation question and found claimant's back pain was causally related to the back injury.  He also found that defendants were liable for payment for the SCS treatment.  Defendants asked for rehearing, arguing that claimant had the burden of demonstrating that the care authorized was unreasonable.  Claimant argued that because defendants had denied liability, they had made no offer of alternative care.  Claimant noted that defendants were attempting to have the best of both worlds.  The petition for rehearing was denied.

At the district court level, the court found the back injury was related to employment.  The court, however, found that claimant had to establish that alternate medical care was reasonable and necessary and that the medical care provided by the employer was unreasonable.  The court concluded that the commissioner's finding that there was not a reasonable alternative course of treatment offered by the defendants was supported by substantial evidence.  The decision of the commissioner was affirmed.

On appeal, defendants argue that there was not substantial evidence to support the findings that claimant's back pain was related to the original injury and that the SCS trial was reasonable and necessary treatment for claimant's back pain. On the first issue, the Court of Appeals concluded that since the commissioner had relied on the findings of Dr. Kuhnlein and Dr. Ledet, there was substantial evidence to support the conclusion that claimant's back injury as related to his employment.  

On the issue of whether the SCS treatment was reasonable and necessary, the Court of Appeals again noted that Dr. Ledet and Dr. Kuhnlein had supported such treatment and that the weight to be given to these physicians was "within the provision of the commissioner."  The court concluded that substantial evidence supported the decision that the SCS trial was reasonable and necessary.

The final question presented was whether the determination that the treatment provided by the employer was unreasonable constituted an abuse of discretion on the part of the commissioner.  The Court of Appeals noted that in the alternate medical care setting, the employee had the burden of proving that the care offered by the employer was unreasonable.  The court noted, however, that when the employer denies liability, the employer no longer had the right to direct care.  The court concludes that in demanding that claimant prove that the care provided was unreasonable in the face of a denial of liability, the employer was attempting to "have the best of both worlds," as claimant had argued.  The court found that "the employer does not get the deference it is afforded in an alternate medical care proceeding after it has denied liability and caused that proceeding to be dismissed."  Because the employer denied liability, the question was not whether the employer was meeting its obligation to provide reasonable treatment, rather claimant only had to prove that the back pain was related to the work injury and the SCS trial was reasonable and necessary to treat the injury.  Because the answer to these questions was supported by substantial evidence, the decision of the commissioner was affirmed and the SCS trial was authorized.