Court of Appeals clarifies compensability analysis for medical services.
By: Rebecca Watkins
This month, SBH received favorable decisions from the Court of Appeals in two cases addressing compensability of medical services under ORS 656.245(1).
In Vukasin v Liberty NW (May 13, 2015), the worker had a 2000 ankle injury with several accepted and denied conditions. In 2009, she had surgery that addressed, in part, synovitis and peroneal tendonitis, both diagnoses that had been accepted under the previous claim. Vukasin argued that because these were accepted conditions, the Board had no choice but to find the surgery compensable – it lacked authority to find they had resolved. The Court of Appeals disagreed and held the Board could find on the record that the prior synovitis and peroneal tendonitis had resolved, and the new diagnoses of those conditions did not relate back to the injury.
In Weiker v Douglas County School District, the worker had a 1999 left leg injury that caused traumatic occlusion of the popliteal artery requiring a graft. In 2009, her doctor recommend a bilateral aortoarterial bypass because her “upstream” arteries had become occluded due to arteriosclerosis (plaque build up). While the popliteal artery graft remained open, the doctor indicated that improving the upstream flow was needed to help keep that graft open in the future. Weiker argued the surgery was thus “for” the compensable injury. The Court of Appeals rejected this argument and held that the Board properly found that the surgery was not materially related to the injury. Although it would treat insufficient blood flow in addition to arteriosclerosis, no evidence connected that insufficient blood flow to the injury.
Two important lessons can be found in these cases. First, the Court of Appeals clarified that the inquiry under ORS 656.245(1) begins by identifying all the conditions a medical service treats, and then determining if any of those conditions can be materially related back to the injury. Second, the Court clarified that the fact a medical service is for the same diagnostic label as accepted under a previous claim does not automatically mean it is for the compensable injury. Evidence of successful treatment or resolution of the diagnosis may break the causal chain.
If you receive a request for medical services under a prior claim, carefully evaluate the past and current medical records to determine if the requested service actually relates to that prior injury. SBH is happy to assist you with any questions.