GQ Corner
Q. On 2/8/20, the claimant injured his left bicep during PT. We received a bill with the diagnosis of major depressive disorder, single episode. His treating doctor determined it is unrelated to the OJI. Please advise if the following wording can be used to file a PLN-11. “Self-insured disputes major depressive disorder, single episode as being related to the compensable injury of 02/08/20. Self-insured contends these conditions from which claimant suffers are pre-existing and non-occupational. The evidence is insufficient to establish that the employment or reported work event are a producing cause of same. Self-insured disputes any disability which arises from this non-compensable condition.”
A. Unless you are being billed for a service associated with the diagnosis, it is unnecessary to file the PLN-11 and my position is that as the form itself indicates that you are denying a “benefit.” The new form already indicates that you are denying “that some of your medical conditions were caused by your work-related injury” and, in completing the form, you are required to complete the “we don’t agree because” language with “facts that explain the denial.” Therefore, the first and last sentences should be removed because they are no explanation at all. Unless you have evidence to support the facts identified in the second sentence, you should not say that. You should never, under any circumstance, articulate a theory such as “pre-existing” unless there is affirmative evidence to support such assertion. The third sentence is correct but, without more, would appear to run contrary to the specific prohibition in Rule 124.2(l). As such, it needs to be modified. You should only state facts. As such, after the colon, you should say: “We received a bill that contained the diagnosis of major depressive disorder, single episode. However, your treating doctor has advised us that it is not related to your on-the-job injury. Such diagnoses require expert evidence of causation to link them to the compensable injury. At this time there is insufficient evidence to establish that the compensable injury is a producing cause of this diagnosis.”
Q. Are we required to send out the 2nd quarter SIBs application to the claimant if they fail to apply for the 1st quarter?
A. You are not. The triggering event for you to send a DWC-52 to the claimant is either the denial or payment of the prior quarter. If you did neither, there is no obligation for you to do anything.
FOLIO
