TREATMENT
After claim closure
RCW 51.36.010 permits the Director to exercise discretion to provide continued treatment in circumstances other than claims closed with a total permanent disability determination. The decision of In re David Malmberg, Dckt. No. 86 1326 (November 12, 1987), to the extent that the Board concluded that the statute only applied in circumstances of total permanent disability, is overruled. ....Debra Reichlin, 00 15943 (2003) [Editor's Note: The Board's decision was appealed to superior court under Grant County Cause No. 01-2-00489-8.]
Aggravation of pre-existing condition
A worker need not prove lighting up of a condition in order to be entitled to treatment. A worker is entitled to treatment if a pre-existing condition was aggravated by the industrial injury or occupational disease. ....Aaron Libby, 04 20487 (2005) [Editor's Note: The Board's decision was appealed to superior court under King County Cause No. 05-2-39669-5 SEA]
Department guidelines
Department guidelines for determining if surgery is medically proper and necessary treatment do not provide the legal basis for the Board to determine if the treatment is proper and necessary. ….Paul Fish, 10 18494 (2011)
Failure to obtain prior authorization
A self-insured employer may be required to pay for surgery even if the provider did not obtain prior authorization if the procedure was medically necessary and proper. Citing Boise Cascade v. Huizar, 76 Wn. App. 676 (1994). ….David Harrington, 97 A033(1999)
The Board will consider a worker's post-surgical improvement in determining whether treatment originally denied by Department or self-insured employer was reasonable and necessary, despite the surgeon's failure to obtain prior authorization or second opinion. ....Zbiegniew Krawiec 90 2281 (1991) [dissent] [Compare In re Iva Labella, BIIA Dec., 89 3586 (1991)].
The nature of the treatment pursued and the reasonableness of the worker's doing so will be considered in determining whether the worker is entitled to benefits. Where worker did not objectively demonstrate that surgery was proper and necessary for treatment of her industrial injury and knew surgery was not authorized, and that benefits had been suspended, Department properly denied responsibility for treatment benefits as well as denying award for time loss compensation and/or permanent partial disability award arising from the surgery. ....Iva Labella, 89 3586 (1991) [Cf. In re Arvid Anderson, BIIA Dec., 65,170 (1986). Compare In re Zbiegniew Krawiec, BIIA Dec., 90 2281 (1991) The Board's decision was appealed to superior court under Spokane County Cause No. 91-2-04329-3.].
Fixity of condition
A worker's refusal to undergo recommended treatment may result in a finding that the conditions are medically fixed. ….Smajo Mesan, 08 22054 (2010)
[Editor's Note: The Board's decision was appealed to superior court under Benton County Cause No. 10-2-03101-1.]The Department can not deny payment of medical benefits on the basis that the worker has reached maximum medical improvement without also making a determination of permanent disability. ....Steve Meeks, 06 20754 (2008)
Whether a claim should remain open for further treatment depends upon the character of the industrially related condition and disability and the expected effect of particular treatment. A claim is ready for closure when the condition and disability are best characterized as essentially permanent, fixed and stable--that is, when with or without treatment, the condition is enduring, not temporary or transient and no fundamental or marked change can be expected. ....Lyle Rilling, 88 4865 (1990) [dissent] [Editor's Note: The Board's decision was appealed to superior court under Grant County Cause No. 90-2-00834-3.]
Hearing aids
In order to require provision of hearing aids without regard to the date treatment was concluded or the claim closed, the ongoing responsibility to provide hearing aids must be stated in an order entered at, or prior to, closing. ....Andrew Carey, 04 18928 (2005) [dissent] [Editor's Note: The Board's decision was appealed to superior court under Pacific County Cause No. 05-2-00377-6.]
Proper and necessary medical and surgical services (RCW 51.336.010)
Medical opinions that establish that a worker's condition would rapidly deteriorate and be life-threatening without further treatment provide a sufficient basis to conclude that the further treatment is proper and necessary. ....Freda Hicks, 01 14838 (2004)
When the authorization of a specific form of treatment is at issue, whether that treatment modality constitutes "proper and necessary medical and surgical services" depends on whether it meets the definition of "medically necessary" contained within WAC 296-20-01002. Unless the treatment modality falls within a category of treatment that is specifically authorized or rejected in all cases by regulations within Chapters 296-20, 296-21 or 296-23, WAC, each individual request for authorization must be examined to see if under the circumstances of the case, it meets the regulatory definition of "medically necessary." Medically necessary treatment may be curative, diagnostic or rehabilitative. So-called "palliative" treatment may still be authorized if it meets the definition of "medically necessary" and is not excluded by other regulatory provisions. Medical treatment that is considered controversial, obsolete, experimental or investigational may also be authorized if its proponent can overcome the presumption that it is not "medically necessary." ….Susan Pleas, 96 7931 (1998) [dissent]
The Board will consider a worker's post-surgical improvement in determining whether treatment originally denied by the Department or self-insured employer was reasonable and necessary, despite the surgeon's failure to obtain prior authorization or second opinion. ....Zbiegniew Krawiec 90 2281 (1991) [dissent] [Compare In re Iva Labella, BIIA Dec., 89 3586 (1991)]
The nature of the treatment pursued and the reasonableness of the worker's doing so will be considered in determining whether the worker is entitled to benefits. Where worker knew surgery was not authorized, and that benefits had been suspended, Department properly denied responsibility for treatment benefits as well as denying award for time -loss compensation and/or permanent partial disability award arising from the surgery. ....Iva Labella, 89 3586 (1991) [Cf. In re Arvid Anderson, BIIA Dec., 65,170 (1986). Compare In re Zbiegniew Krawiec, BIIA Dec., 90 2281 (1991).The Board's decision was appealed to superior court under Spokane County Cause No. 91-2-04329-3.]
Recoupment of medical expenses - See DEPARTMENT Authority to recoup overpayment of benefits
Spinal column stimulator
Although implantation of spinal column stimulator is "controversial" treatment per medical aid rules, such treatment may be authorized if the treatment is rehabilitative and reflective of accepted standards of good practice, thereby satisfying the requirements that it be "medically necessary" treatment within the meaning of WAC 296-20-01002 and "proper and necessary medical and surgical services" within the meaning of RCW 51.36.010. ….Susan Pleas, 96 7931 (1998) [dissent]
Subsequent condition impairing recovery
WAC 296-20-055 allows the Department to authorize treatment for a pre-existing condition that retards recovery from the effects of an industrial injury, but does not allow the Department to authorize treatment for unrelated conditions developed subsequent to the industrial injury. ....Kris Ayers, 04 10250 (2005)