Moses, Jamie v. Five Star Food Service, Inc.

2021 TN WC 192
CourtTennessee Court of Workers' Compensation Claims
DecidedJune 21, 2021
Docket2020-01-0875
StatusPublished

This text of 2021 TN WC 192 (Moses, Jamie v. Five Star Food Service, Inc.) is published on Counsel Stack Legal Research, covering Tennessee Court of Workers' Compensation Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Moses, Jamie v. Five Star Food Service, Inc., 2021 TN WC 192 (Tenn. Super. Ct. 2021).

Opinion

FILED Jun 21, 2021 03:19 PM(ET)

TENNESSEE COURT OF WORKERS' COMPENSATION CLAIMS

TENNESSEE BUREAU OF WORKERS’ COMPENSATION IN THE COURT OF WORKERS’ COMPENSATION CLAIMS

AT CHATTANOOGA Jamie Moses, ) Docket No.: 2020-01-0875 Employee, ) V. ) Five Star Food Service, Inc., ) State File No.: 32242-2020 Employer, ) And ) Judge Thomas Wyatt Amerisure Partners Ins. Co., ) Carrier. )

EXPEDITED HEARING ORDER FOR MEDICAL BENEFITS (DECISION ON THE RECORD)

Jamie Moses requested an Expedited Hearing on the record for left-shoulder/rotator cuff surgery recommended by the treating physician. The Court entered a Docketing Notice setting deadlines for filing evidence and briefs by June 15, 2021. Five Star responded that the Court should not hear the surgery issue because Ms. Moses failed to comply with timing provisions in the Bureau’s rules. Alternatively, it argued Ms. Moses failed to prove the medical necessity of the disputed surgery. For the reasons below, the Court orders Five Star to authorize the surgery.

History of Claim

On May 20, 2020, Ms. Moses felt a pulling sensation and immediate pain when she slung a heavy tote into a truck at work. Five Star accepted the claim and approved a referral to orthopedist Dr. Jason Spangler after a brief period of care at a walk-in clinic.

Dr. Spangler first saw Ms. Moses in mid-June. He injected the shoulder and, with the benefit of MRI results, diagnosed a sprain that acutely caused joint inflammation in her already-arthritic left shoulder. He also diagnosed small tendon tears in the left rotator cuff. He ordered physical therapy and injected the shoulder again on August 17. He ordered arthroscopic surgery on September 28 because conservative measures failed to provide relief. Five Star submitted the surgery recommendation to utilization review (UR). A physician reviewer who did not examine Ms. Moses declined to certify the recommended surgery. By letter dated October 6, the reviewer concluded that the recommended surgery did not conform to applicable treatment guidelines because: the surgery should not be performed until six months after the last injection to the affected area; Ms. Moses had full strength in the muscles of her left rotator cuff; and the MRI showed only tiny tears in the rotator cuff.

Ms. Moses appealed the UR decision. On November 10, the Bureau’s Medical Director upheld the non-certification because “the medical records do not reflect that sufficient and consistent conservative treatment has failed.”!

Ms. Moses filed a Petition for Benefit Determination on December 3 seeking authorization of the surgery. The Dispute Certification Notice listed Five Star’s defense as: “Utilization Review denial of request for surgery.” It later added lack of medical causation as a defense. Ms. Moses requested an on-the-record Expedited Hearing, to which Five Star consented.

In support of the requested surgery, Ms. Moses submitted an affidavit signed by Dr. Spangler on April 7.2 He concluded that Ms. Moses’s shoulder injuries, need for treatment, and disablement “arose primarily out of and in the course and scope of employment with [Five Star] and the employment contributed more than fifty percent (50%) in causing [her] left shoulder injuries and the need for treatment.” Regarding the medical necessity of the recommended surgery, Dr. Spangler stated:

In my opinion, my request for surgery falls within the treatment guidelines and is absolutely medically necessary. Ms. Moses has tried conservative treatment including an AC Joint injection which only gave her some relief and a subacromial injection which did not afford complete relief. The MRI shows partial thickness tearing of the rotator cuff and a superior glenoid labrum tear which need to be surgically repaired along with arthroscopic clearing of inflammation in the AC joint. This is the only way to get this patient back to maximum medical improvement and I do not understand why workers’ compensation would deny this patient such a typical, usual remedy for such a left shoulder injury.

Five Star relied on the opinions of the UR reviewer and Medical Director to support

' The UR physician stated the guidelines required three to six months of failed conservative care. Dr. Spangler recommended surgery approximately four and one-half months after Ms. Moses began her course of conservative treatment.

* Dr. Spangler last saw Ms. Moses in his office in January 2021. His diagnosis and treatment recommendations on that date did not change from the previous visits its position the requested surgery is not medically necessary.? Findings of Fact and Conclusions of Law

To recover, Ms. Moses must present evidence from which the Court can determine she is likely to prevail at a hearing on the merits in showing that the disputed surgery is reasonable and necessary to treat a compensable injury. See generally McCord v. Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *9 (Mar. 27, 2015). Under the Workers’ Compensation Law, an employer’s obligation is limited to providing treatment that is made “reasonably necessary” by the work injury. Tenn. Code Ann. § 50-6-204(a)(1)(A) (2020).

Five Star first argued that the surgical issue is not ripe for consideration because Ms. Moses did not comply with timing provisions in the Bureau’s UR regulations. Specifically, it argued that Ms. Moses failed to timely file a petition for benefit determination requesting a hearing on the Medical Director’s denial of the surgery recommended by Dr. Spangler.

Tennessee Compilation Rules and Regulations 0800-02-06-.07(6) prescribes a period of seven business days after the date of the Medical Director’s decision for filing a petition on the decision. If no petition requesting a hearing of the dispute is made within the seven-business-day period, the Medical Director’s denial “shall remain effective for a period of 6 months from the date of the decision” unless there is “material change documented by the treating physician that supports a new review or other information that was not used by the [reviewing physician] in making the initial decision.” Tenn. Comp. R. & R. 0800-02-06-.06(7), 0800-02-06-.07(5) (January 2017).

Ms. Moses filed a petition disputing the Medical Director’s denial of surgery outside the limitations period in the Bureau’s rules. Thus, by regulation, the Medical Director’s denial stayed in effect for six months, or until May 10, 2021. The issue here is whether Ms. Moses’ failure to comply with the limitations period meant she could not file a petition to challenge the UR denial until after May 10. Five Star argued that Ms. Moses’ failure to file her petition within seven business days of the Medical Director’s denial meant she had to begin the entire surgical-authorization process again after May 10. In other words, she could not bring the surgery issue before the Court until she saw Dr. Spangler after May 10, he again recommended surgery, Five Star again submitted the recommendation to UR, and the UR procedure was exhausted.

In essence, Five Star argued that Ms. Moses had no judicial review of the Medical Director’s denial of her surgery because she did not exhaust the administrative remedy in

> Five Star expressed concern that the Court would not consider the evidence it filed because the Docketing Notice stated the Court had sufficient information to decide the medical-necessity decision on the record. That is not the case. The Court’s Docketing Notice gave Five Star the opportunity to submit evidence and the Court considered the evidence Five Star submitted. the Bureau’s rules—filing a petition within seven business days to challenge the Medical Director’s denial.

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Related

§ 50-6-204
Tennessee § 50-6-204(a)(1)(A)

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2021 TN WC 192, Counsel Stack Legal Research, https://law.counselstack.com/opinion/moses-jamie-v-five-star-food-service-inc-tennworkcompcl-2021.