W.C. No. 4-114-314.Industrial Claim Appeals Office.
January 7, 2005.
FINAL ORDER
The claimant seeks review of two orders of Administrative Law Judge Mattoon (ALJ Mattoon) which denied the claimant’s request for specific medical treatments. The claimant argues the ALJ impermissibly countermanded a prior determination that the claimant’s “condition” is related to the industrial injury. The claimant also contends the ALJ improperly engaged in the “active practice of medicine.” We affirm.
Much of the factual background concerning the ALJ Mattoon’s two orders is summarized in our Order of Remand dated December 15, 2003. Berumen v. Arapahoe County Department of Social Services, W.C. No. 4-114-314
(December 15, 2003). The statement of facts contained in our order is incorporated herein.
ALJ Mattoon’s order of March 30, 2004, was entered pursuant to our Order of Remand. The issue addressed in the March 30 order is whether the claimant should receive botox injections as a form of continuing medical treatment after maximum medical improvement (MMI) pursuant to Grover v. Industrial Commission, 759 P.2d 705 (Colo. 1988). One of the claimant’s authorized treating physicians, Dr. Hall, opined the claimant suffers from thoracic outlet syndrome (TOS) as a consequence of the 1991 occupational disease, and that botox injections commencing in May 2003 provide relief of the claimant’s symptoms. In contrast, the respondent presented the opinion of Dr. Morgan, an independent medical examiner, who opined the claimant probably does not suffer from TOS and, in any event, does not need botox injections. Dr. Morgan stated the claimant’s symptoms are too diffuse to make a definitive diagnosis, and that in these circumstances invasive procedures such as injections are not warranted. (Tr. May 12, 2003, Pp. 34-36, 40-41; Report of Dr. Morgan, September 30, 2003).
In the March 30 order ALJ Mattoon credited the opinions of Dr. Morgan and found the claimant failed to prove that the need for botox injections, if any, is causally related to the 1991 occupational disease. Further, the ALJ found the claimant failed to prove that botox injections are reasonably necessary to relieve the effects of the 1991 injury.
The February 4, 2004, order, insofar as pertinent, concerns the claimant’s entitlement to trigger point injections and the drug neurontin as forms of Grover medical benefits. The evidence concerning these treatments was similar to that presented about the botox injections. Dr. Hall began performing trigger point injections in 2000 and recommended the use of neurontin to treat the claimant’s symptoms. Dr. Morgan opined that the claimant does not need these treatments and they are fostering a dependence on potentially dangerous invasive procedures and medications. Instead, Dr. Morgan recommended the claimant pursue a course of weight loss and exercise to remedy her many symptoms and deconditioned state.
In the February 4 order ALJ Mattoon credited the opinions of Dr. Morgan and found the claimant failed to prove that neurontin and trigger point injections are reasonable and necessary treatments for her condition. Specifically, the ALJ credited Dr. Morgan’s opinion that the claimant does not have neuropathic pain, and therefore, neurontin is not necessary to treat the claimant’s pain and poses a risk of side effects. The ALJ further credited Dr. Morgan’s opinion that trigger point injections are best reserved for short-term use to treat acute pain, and that Dr. Hall has used them for too long to treat the claimant’s diffuse pain.
I.
On review, the claimant first contends that ALJ Mattoon’s orders are erroneous because “all of the [original] treating physicians opined Claimant suffered Thoracic Outlet Syndrome” and all treated that condition. Under these circumstances the claimant asserts ALJ Mattoon was prohibited from finding that she failed to establish the existence of TOS, especially because the “condition was admitted and treated for a prolonged period of time.” Similarly, the claimant reasons the ALJ was precluded from finding the proposed treatments are not reasonable and necessary. The claimant cites no authority in support of her position, and we disagree with her arguments because we conclude they are not consistent with the facts or the law.
The claimant was seeking an order requiring the respondent to pay for botox injections, trigger point injections and neurontin based on Dr. Hall’s opinion that the claimant suffers from TOS and needs these treatments as Grover-style medical benefits. However, it has long been established that an award of Grover medical benefits is general in nature and is subject to the respondent’s right to challenge whether particular medical treatment is causally-related to the industrial injury, and whether the treatment is reasonable and necessary to relieve the effects of an injury-related condition. Grover v. Industrial Commission, 759 P.2d at 712; Hanna v. Print Expediters, Inc., 77 P.3d 863, 866
(Colo.App. 2003). The questions of whether a particular condition is related to an industrial injury, and whether a proposed treatment is reasonable and necessary, are issues of fact for determination by the ALJ. Kroupa v. Industrial Claim Appeals Office, 53 P.3d 1192 (Colo.App. 2002); Wal-Mart Stores, Inc. v. Industrial Claims Office, 989 P.2d 251
(Colo.App. 1999). We must uphold the ALJ’s factual determinations if supported by substantial evidence in the record. Section 8-43-301(8), C.R.S. 2004.
The claimant’s assertion notwithstanding, the mere fact that the respondent may have paid for some treatments which Dr. Hall ascribes to TOS does not require them to continue paying for such treatments if they obtain information which casts doubt on the existence of TOS, its cause, or the reasonableness of specific treatments. Snyder v. Industrial Claim Appeals Office, 942 P.2d 1337 (Colo.App. 1997) (general admission of liability for medical benefits did not require respondents to continue to pay for treatment where subsequent information demonstrated the need for treatment was not related to injury). Although the claimant asserts that TOS has been diagnosed from the onset of the claimant’s occupational disease, ALJ Mattoon found that Dr. Hall did not make any firm diagnosis of TOS until 1998, after the claimant reached MMI for the prior diagnoses of bilateral carpal tunnel syndrome, bilateral Guyon’s canal syndrome, and bilateral de Quervain’s syndrome. (Order of March 30, Finding of Fact 4). This finding constitutes a plausible interpretation of the evidence, and we may not interfere with it. Section 8-43-301(8). Moreover, the record reflects that the claimant has previously attempted to obtain surgical treatment for TOS, and on both occasions ALJ Stuber found that the claimant failed to prove that she has TOS, or if she does that the proposed surgery was reasonable and necessary. (ALJ Stuber’s Summary Order of August 18, 1999; ALJ Stuber’s Order of November 26, 2002). Thus, the assertion that the respondent is attempting to relitigate a previously resolved issue concerning the cause of TOS is without merit.
Insofar as the claimant contends the ALJ’s findings concerning causation and the reasonableness and necessity for the proposed treatments are not supported by the evidence, we disagree. The reports and testimony of Dr. Morgan provide ample basis for ALJ Mattoon’s findings and conclusions, and we may not interfere with her decision to credit this evidence. Kroupa v. Industrial Claim Appeals Office, supra
(ALJ’s reliance on testimony of respondents’ expert that proposed surgery was not reasonable and necessary entitled to deference on appeal even though claimant presented conflicting expert testimony).
II.
The claimant next contends that ALJ Mattoon was “practicing medicine” by instructing the treating physician not to prescribe treatments which he believes are necessary. According to the claimant, if the respondent wished to challenge Dr. Hall’s treatment recommendations, it should have found a physician to agree with its position and sought a change of physician. We disagree with this argument.
The ALJ has express statutory jurisdiction to “decide all matters arising under articles 40 to 47” of the Act, and, therefore, to enter appropriate findings and decisions on such matters. Section 8-43-201, C.R.S. 2004; Dee Enterprises v. Industrial Claim Appeals Office, 89 P.3d 430, 434 (Colo.App. 2003). This jurisdiction encompasses the power to determine whether, as a condition of compensability, the need for treatment is causally related to the industrial injury, and whether particular treatment is reasonable and necessary. Section 8-41-301(1)(c), C.R.S. 2004, section 8-42-101(1)(a), C.R.S. 2004; Kroupa v. Industrial Claim Appeals Office, supra; Wal-Mart Stores, Inc. v. Industrial Claims Office, supra.
The determinations made by the ALJ in this case are fully within her express authority, and no different than those made in hundreds of other cases. Further, the ALJ is not “practicing medicine” in the sense that she is compelling the treating physician to prescribe one course of treatment or another, she merely determined that under the Act the respondent is not liable for specific treatments recommended by Dr. Hall.
The claimant asserts that she may suffer “severe personal injuries” if she is forced into “withdrawal from neurontin.” While the record does not establish a factual basis for this assertion, we note that in some cases respondents may be required to pay for medical treatment unrelated to an industrial injury if reasonably necessary to promote optimal recovery from the industrial injury. See Public Service Co. v. Industrial Claim Appeals Office, 979 P.2d 584 (Colo.App. 1999).
Insofar as the claimant makes other arguments. We find them to be without merit. The respondent’s request for attorney fees is denied. The fact pattern presented here affords at least some basis for the claimant’s assertion that the respondent should be held liable for the requested treatments.
IT IS THEREFORE ORDERED that ALJ Mattoon’s orders dated February 19, 2004, and March 30, 2004, are affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
____________________ David Cain
____________________ Kathy E. Dean
Gloria Berumen, Canon City, CO, George Shipley, Arapahoe County Department of Social Services, Personnel Department, Littleton, CO, Sundee Hahn, County Technical Services, Denver, CO, William A. Alexander, Jr., Esq., Colorado Springs, CO, (For Claimant).
Anne Smith Myers, Esq., Denver, CO, (For Respondent).