GQ Corner

Q. We obtained a peer review addressing the extent of the compensable injury. Our peer reviewer opined that the compensable injury is limited to a lumbar strain. Thus, we filed a PLN-11 disputing the compensability of various lumbar pathology revealed on MRI study. Recently, our utilization review agent (URA) pre-authorized as medically necessary a low back surgery for the disputed pathology. Are we now liable for these costs given the pre-authorization?

A. No. The role of the URA is to evaluate only medical necessity, and not extent of injury or the relatedness of the treatment at issue. Unless and until you become subject to an adverse designated doctor opinion, legal decision, or formal agreement binding you to accept the disputed conditions underpinning the requested surgery, you may continue to maintain your dispute without incurring liability for the costs associated therewith.

Q. The treating doctor issued a full duty work release, but the claimant and the claim employer emphatically believe that he is unable to do so as a result of his work injury. Consequently, the claim employer instructed him to remain off work entirely and to re-evaluate the prospect of returning to work at a later date. If we dispute disability and entitlement to TIBS based on the full duty work release, are we likely to prevail as to those issues?

A. Under the circumstances, probably not. Disability is a fact issue that may be resolved in favor of the claimant absent any medical evidence. The Appeals Panel has emphasized that a claimant may establish disability through his or her lay testimony alone without an expert medical opinion to support same. In this instance, the circumstances (and particularly, the agreement of the employer as to the claimed inability to work) yield a relatively low probability of prevailing on a disability dispute notwithstanding the purported full duty release.