E-Town Quarry v. Goodman

12 S.W.3d 708, 2000 Ky. App. LEXIS 15, 2000 WL 199402
CourtCourt of Appeals of Kentucky
DecidedFebruary 18, 2000
DocketNo. 1999-CA-000781-WC
StatusPublished
Cited by6 cases

This text of 12 S.W.3d 708 (E-Town Quarry v. Goodman) is published on Counsel Stack Legal Research, covering Court of Appeals of Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
E-Town Quarry v. Goodman, 12 S.W.3d 708, 2000 Ky. App. LEXIS 15, 2000 WL 199402 (Ky. Ct. App. 2000).

Opinion

OPINION

McANULTY, Judge.

E-Town Quarry (“E-Town”) petitions for review of an opinion of the Workers’ Compensation Board affirming the decision of the Administrative Law Judge (“ALJ”) holding E-Town responsible for certain medical expenses related to psychiatric treatment incurred by Gary Goodman. After reviewing the record, we affirm.

In February 1995, while an employee of E-Town, Goodman suffered an'extensive injury to his right arm when it was crushed in a conveyor. In addition to the physical injuries, Goodman was diagnosed to be suffering from post-traumatic stress disorder, depression, and sleep disturbance related to the accident. Goodman was evaluated and received psychiatric treat[709]*709ment from Dr. Shared Patel. Based on the evidence, including testimony from several physicians and two psychiatrists, Goodman was found to be totally occupationally disabled with a need for further psychiatric treatment. Dr. Patel has continued to provide psychiatric treatment to Goodman consisting of a weekly individual session for counseling, pharmacological management of the prescription medicine Luvox, and one weekly group counseling session.

In May 1997, E~Town sought a Utilization Review consistent with Kentucky Administrative Regulations (“KAR”), Title 803, Chapter 25, Section 190, to assess the medical necessity and appropriateness of Goodman’s continued psychiatric treatment. See KRS 842.035(5). On May 29, 1997, Dr. Daniel Wolen, who is certified in occupational and environmental medicine, conducted a review of the records for the Utilization Review and questioned the need for the treatment schedule followed by Dr. Patel. Dr. Wolen opined that Goodman’s psychological condition had not changed during the year prior to the review and that he was no longer suicidal, so close management of his condition was no longer necessary. Dr. Wolen believed that Goodman’s counseling sessions could be significantly reduced or eliminated with a lower level of care by a psychologist or social worker and only occasional visits to a psychiatrist for review of his drug treatment. Given that his evaluation was based entirely on a review of medical documents, however, Dr. Wolen recommended that Goodman also be seen and evaluated by a psychologist concerning future treatment.

In July 1997, Dr. Brian Monsma, a licensed clinical psychologist, interviewed Goodman and performed some clinical testing. Dr. Monsma found that Goodman suffered from post-traumatic stress disorder and depression, but felt that his condition had been treated appropriately and was improving. He recommended a limited three-month period of continued group therapy sessions with continued provision of Luvox by a family practice physician and occasional follow-up appointments with Dr. Patel when needed. Dr. Monsma considered Goodman a good candidate for vocational rehabilitation.

Following completion of the Utilization Review, E-Town’s workers’ compensation carrier refused to continue paying for Goodman’s treatment by Dr. Patel. On January 5,1998, E-Town filed a notice of a medical fee dispute and a motion to reopen the workers’ compensation claim to resolve the dispute over payment for Dr. Patel’s psychiatric treatment. KRS 342.020. The motion to reopen was assigned to an arbitrator, who found that the treatment rendered by Dr. Patel was compensable. As part of the dispute resolution process, E-Town filed a motion requesting that the arbitrator require Goodman to complete or exhaust the Utilization Review process pri- or to a ruling on the motion to reopen, which the arbitrator denied.

On June 2, 1998, E-Town requested a hearing before an administrative law judge. The ALJ conducted a hearing on October 6,1998, at which Goodman and his wife testified. The ALJ also considered the reports of Dr. Wolen and Dr. Monsma, the deposition of Dr. Patel, and the reports of several surgeons who had treated Goodman. Goodman testified that his depression worsened during a four-month period he did not attend the counseling sessions because of the dispute over payment with his employer. He stated that the counsel-ling sessions helped him cope with his depression and other emotional problems. Goodman’s wife also stated that her husband appeared to benefit from the individual counseling and group therapy sessions. Dr. Patel indicated that the counseling sessions had helped Goodman in the past and that the group therapy sessions allowed him to deal with his disability and emotional problems through interaction with others in a similar situation. Dr. Patel felt continued psychiatric treatment would benefit Goodman. At the hearing, E-Town raised the issue of exhaustion of the [710]*710Utilization Review process. The ALJ accepted the medical opinion of Dr. Patel and found the testimony of Goodman and his wife credible. He found that continued psychiatric treatment, including the group therapy sessions, was reasonable and necessary, and concluded that the costs associated with this treatment were compensa-ble. The ALJ did not specifically address E-Town’s exhaustion issue in his opinion, but he implicitly rejected it.

On appeal to the Workers’ Compensation Board, E-Town relied solely on the exhaustion issue pertaining to the Utilization Review procedure. The Board found that there was sufficient evidence in the record to support the ALJ’s conclusion that continuation of the psychotherapy treatment was reasonable and necessary. It also rejected E-Town’s argument that Goodman’s failure to exhaust the administrative Utilization Review procedure allowed it to avoid payment of the medical bills associated with Dr. Patel’s treatment. The Board also indicated in its opinion that E-Town was estopped from relying on Goodman’s failure to exhaust the Utilization Review because it had not strictly complied with the appeal procedures set forth under the review process as set forth in 803 KAR 25:190. E-Town has appealed the Board’s decision to this Court.

On appeal, E-Town has raised a single issue as stated in its brief: “Should the Appellant have to pay for medical services when Utilization Review deemed them to be unnecessary and there is no appeal of that decision?” E-Town argues that in order to effectuate the purpose of the Utilization Review process, an employer must be able to rely on the opinion and recommendation of the reviewer when the employee fails to appeal or contest that opinion.

In rejecting E-Town’s position, the Board stated in its opinion as follows:

The utilization review regulation is created pursuant to KRS 342.020. It is designed to help the parties resolve medical expense issues without the need to resort to litigation. It is not designed nor authorized to replace the responsibility of Arbitrators and Administrative Law Judges to decide medical disputes that are presented to them.... There is nothing in the regulation nor the statute that accords special weight to evidence from a UR [Utilization Review] doctor once the matter is brought to adjudication. Even if the regulation attempted to create such an impact, it would be in conflict with the adjudicatory rights established by the Kentucky Legislature, which in workers’ compensation rests solely with Arbitrators and Administrative Law Judges. See

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Cite This Page — Counsel Stack

Bluebook (online)
12 S.W.3d 708, 2000 Ky. App. LEXIS 15, 2000 WL 199402, Counsel Stack Legal Research, https://law.counselstack.com/opinion/e-town-quarry-v-goodman-kyctapp-2000.