Washington Board of Industrial Insurance Appeals Makes In Re Michael Reed a Significant Decision
On March 7, 2023, the Washington Board of Industrial Insurance Appeals published its Significant Decisions from 2022. Each year the Board classifies a small number of decision and orders as “significant”, meaning they contain an analysis or decision of substantial importance.
The Board originally published In re Michael Reed, BIIA Dec., 21 17153 (2022) on September 22, 2022. The claimant in this case slipped and fell while working for a roofing company, resulting in a lower back injury. The Department accepted a lumbar strain but issued an order segregating the condition of lumbar radiculopathy. Claimant appealed. The industrial appeals judge found the injury did not cause or aggravate the condition of lumbar radiculopathy. Moreover, relying on In Re Jeremy Carrigan BIIA Dec., 20 12899 (2021), the industrial appeals judge found the Department did not accept responsibility for the lumbar radiculopathy under Maphet when it authorized the injections treat the accepted lumbar sprain.
Claimant filed petition for review, arguing that the Department did accept responsibility for his lumbar radiculopathy when it authorized injections and attempting to distinguish this case from Jeremy Carrigan. In that case, the Department had segregated the conditions of L5-S1 disc protrusion and multi-level spine degeneration. Testimony indicated the injections were both diagnostic and therapeutic. The Board held that because the injections were authorized only to treat the accepted lumbar strain, the authorization did not constitute acceptance under Maphet.
In this case, the Board found the facts were similar to Jeremy Carrigan in that it also involved an accepted lumbar sprain/strain. This case differed from Jeremy Carrigan because the record showed that practitioners never treat a sprain with epidural, rather, these injections only treat nerve root irritation. However, the record also indicated that lumbar injuries are generally diagnosed as sprain/strains initially and diagnoses evolve if pain persists. The Board identified the issue as whether diagnostic procedures under an already accepted condition trigger Maphet acceptance.
The Board summarized the Court’s statutory interpretation of WAC-296-20-01002 which provides the same definition of acceptance and accepted condition, and similar definitions for the term authorized. Looking at the rule further, the Board held that in this case, although WAC-296-20-01002 allows the Department to accept responsibility for reimbursing providers for specific treatment, services, or equipment provided for the diagnosis of the condition, the same rule specifies that no condition may be accepted without one or more diagnostic codes. In other words, “for a condition to be accepted, it must have already been diagnosed.” Here, the Department authorized the lumbar injections so claimant’s doctor could pinpoint an evolving and potentially claim related diagnosis. As such, authorization in this case signaled a mere intent to provide diagnostic services only by only authorizing services under the already diagnosed and previously accepted lumbar sprain/strain. In essence, the Board held Maphet does not apply to undiagnosed conditions and affirmed the Department’s segregation order.
We are seeing more cases in which the Board narrows the scope of Maphet, which is encouraging. In addition, this decision highlights the importance of specifying if a treatment authorization is for diagnostic purposes only.
For any questions about this case to discuss the impact Maphet at large, please do not hesitate to contact me at 503-595-6114 or .
Posted by Liz Aaberg.
