Vanveldhuizen, John v. Crown Automotive Group, Inc.

2019 TN WC 3
CourtTennessee Court of Workers' Compensation Claims
DecidedJanuary 8, 2019
Docket2018-01-0388
StatusPublished

This text of 2019 TN WC 3 (Vanveldhuizen, John v. Crown Automotive Group, 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
Vanveldhuizen, John v. Crown Automotive Group, Inc., 2019 TN WC 3 (Tenn. Super. Ct. 2019).

Opinion

FILED Jan 08, 2019 02:11 PM(ET)

TENNESSEE COURT OF WORKERS' COMPENSATION CLAIMS

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

AT CHATTANOOGA John Vanveldhuizen, ) Docket No.: 2018-01-0388 Employee, ) Vv. ) Crown Automotive Group, Inc., ) State File No.: 79301-2017 Employer, ) And ) FFVA Mutual Ins. Co., ) Judge Thomas Wyatt Carrier. ) )

EXPEDITED HEARING ORDER FOR ADDITIONAL MEDICAL BENEFITS

This matter came before the Court on January 3, 2019, for an in-person Expedited Hearing requested by John Vanveldhuizen.! The issue is whether Crown Automotive Group, Inc. (Crown) must authorize a third lumbar surgery recommended by the treating physician. Crown denied the surgery based on a utilization review (UR) physician’s opinion that the surgery was not medically necessary. For the reasons below, the Court orders Crown to authorize the surgery.

History of Claim

Mr. Vanveldhuizen injured his low back at work. Crown accepted the claim and authorized treatment with orthopedist Dr. Jay Jolley, who diagnosed radiculopathy caused by a moderate-to-large L4-5 disk herniation.

Dr. Jolley performed authorized L4-5 microdiskectomy surgery on February 28, 2018. He noted in his operative report that Mr. Vanveldhuizen “was at risk for a recurrent piece of disk herniating, given his relatively young age.”” Dr. Jolley performed a second authorized L4-5 microdiskectomy eleven days after the first surgery.

Mr. Vanveldhuizen requested an on-the-record determination, but the Court set an in-person hearing on Crown’s request.

? Mr. Vanveldhuizen is thirty-eight years old. Part of Crown’s argument against authorizing the recommended surgery arises from the circumstances leading up to the second surgery. Mr. Vanveldhuizen testified that the pain he experienced after the first surgery severely worsened when he drove to and from his first post-surgery visit with Dr. Jolley.’ However, Dr. Jolley’s March 11 operative report noted that Mr. Vanveldhuizen reported his left-leg pain resolved after the first surgery, but it immediately returned because he “thinks” he hit a bump in the road’ while driving home from the “office.” Dr. Jolley stated in the operative note that, on March 7, Mr. Vanveldhuizen underwent an MRI that revealed a recurrent L4-5 herniated disk. Even in consideration of the alleged report that Mr. Vanveldhuizen’s pain returned when his car struck a bump in the road, Dr. Jolley stated in his operative note, “I still feel this is related to the initial injury.”

The second surgery failed to relieve Mr. Vanveldhuizen’s back and left-leg pain. Dr. Jolley ordered physical therapy, which significantly increased his pain. Mr. Vanveldhuizen testified that Dr. Jolley cancelled the therapy, but the therapist notes indicate that the provider discharged him due to missing scheduled appointments.° In any event, Dr. Jolley ordered a May 7 MRI that showed a “probable combination of scar and posterior disc bulging which mildly deforms the ventral thecal sac but does not cause significant mass effect.”

Dr. Jolley mentioned the possibility of a second recurrent herniated disk in his note documenting the second surgery, writing: “[w]e also discussed the fact that if a third large herniation occurs, then he unfortunately will likely need to consider a fusion or disk replacement.” Dr. Jolley considered the May 7 MRI results to confirm his concern about another recurrent herniated L4-5 disk and ordered fusion surgery.

Crown submitted the surgery recommendation to UR. Dr. Richard Lutz, a board- certified orthopedist, performed the assessment. Dr. Lutz did not examine Mr. Vanveldhuizen but determined medical necessity based on documentation provided him by Crown. Dr. Lutz concluded the surgery was not medically necessary under the Bureau’s treatment guidelines because the documentation he received did not contain:

* Mr. Vanveldhuizen testified this was his first post-surgery driving experience, and that the round-trip involved one and one-half hours of driving.

“Mr. Vanveldhuizen denied that his pain worsened when his car struck a bump in the road, and he denied telling Dr. Jolley anything of that nature.

* The Court interprets “office” to refer to Dr. Jolley’s office.

° Records indicate that Mr. Vanveldhuizen participated in five therapy sessions following the second surgery. e flexion/extension x-rays documenting lumbar instability; MRI evidence of nerve root compression;

e records reflecting whether Mr. Vanveldhuizen’s symptoms progressed or regressed during non-surgical care such as physical therapy and spinal injections;* and

e apsychosocial screen.

Dr. Lutz also based his opinion on a statement in the Bureau’s treatment guidelines recommending against fusion surgery for degenerative disk disease and/or disk herniation suffered by employees with workers’ compensation claims. Mr. Vanveldhuizen unsuccessfully appealed Dr. Lutz’s decision to the Bureau’s medical director, and Crown denied authorization for the surgery.

Mr. Vanveldhuizen filed this claim to compel Crown to authorize the surgery. Afterward, Crown’s attorney wrote Dr. Jolley for his opinion whether Mr. Vanveldhuizen’s first recurrent L4-5 herniation primarily arose when he hit a bump while driving. Dr. Jolley responded that the first recurrent disk was “a result primarily from the traumatic annulotomy secondary to the [original] disc herniation.” Crown’s attorney also questioned why Dr. Jolley recommended fusion surgery, to which Dr. Jolley answered that Mr. Vanveldhuizen needed it “given the herniation & the instability now present.”

Mr. Vanveldhuizen submitted Dr. Jolley’s affidavit at the Expedited Hearing. In it, Dr. Jolley elaborated as follows on his opinion that surgery is medically necessary:

In my opinion, my request for surgery falls within the treatment guidelines and is absolutely medically necessary. Mr. Vanveldhuizen has lumbar spine instability and radiculopathy, as documented in my records and by my physical examination and we have tried conservative care such as physical therapy which only makes Mr. Vanveldhuizen’s pain and instability worse. Furthermore, we have tried two prior microdiscectomies and Mr. Vanveldhuizen developed a third recurrent herniation clearly indicating a fusion procedure is necessary as Dr. Lutz’ own report makes clear.

’ Dr. Jolley contended in his response to an inquiry made by Crown’s counsel and, later in his affidavit, that the MRI taken after the second surgery documented lumbar instability.

* The records documenting Mr. Vanveldhuizen’s participation in physical therapy were available but not sent to Dr. Lutz.

* Dr. Lutz’s report stated: “[a]fter failure of two discectomies on the same disc, fusion may be an option at the time of the third discectomy, which should also meet the ODG criteria. (See ODG Indication for Surgery—Discectomy.)” Mr. Vanveldhuizen relied on Dr. Jolley’s medical-necessity opinion, while Crown urged the Court to uphold its denial of the surgery based on the opinions of Dr. Lutz and the medical director. Crown also contended that the symptoms underlying Mr. Vanveldhuizen’s need for the third surgery did not arise primarily out of and in the course and scope of employment because they were caused by him hitting a bump while driving. Lastly, Crown contended that the Court should deny the surgery because Mr. Vanveldhuizen failed to comply with physical therapy.

Findings of Fact and Conclusions of Law

Mr. Vanveldhuizen seeks an order requiring Crown to authorize the recommended fusion surgery. He need not prove his entitlement to the surgery by a preponderance of the evidence but instead must present sufficient evidence showing he would likely prevail on that issue at a hearing on the merits. McCord v.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Thomas v. Aetna Life & Casualty Co.
812 S.W.2d 278 (Tennessee Supreme Court, 1991)

Cite This Page — Counsel Stack

Bluebook (online)
2019 TN WC 3, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vanveldhuizen-john-v-crown-automotive-group-inc-tennworkcompcl-2019.