Byron Gulley v. Hope Youth Ranch
2017 La. LEXIS 549
| La. | 2017Background
- Byron Gulley was injured at work (June 2009) with multiple painful areas including low back, left hip, leg, shoulder, ankle; pain management physician Dr. Domangue diagnosed chronic L5 radiculopathy as primary source of significant low back/left hip/leg pain.
- Dr. Domangue sought a trial of a spinal cord stimulator (SCS) after conservative care and injections failed; psych clearance obtained; employer/insurer denied authorization twice and Medical Director denied on both administrative appeals.
- Medical Director denied the second SCS trial request because the claimant had multifocal pain and the topography of pain was not "amenable to stimulation coverage (the entire painful area has been covered)."
- Office of Workers’ Compensation hearing officer affirmed, interpreting the guideline to require that SCS address every painful area of the body; the court of appeal affirmed on review.
- Louisiana Supreme Court granted writ, concluded the Medical Director and hearing officer misinterpreted 40 La. Admin. Code Pt. I, §2113(A)(2)(c)(v) by expanding "topography of pain" to require coverage of every painful region of the body, and reversed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does MTG require SCS to cover every painful body region? | MTG refers to discrete anatomical topography; SCS need only cover the targeted painful area (e.g., L5 distribution). | MTG requires that the entire painful area be covered; multifocal pain defeats SCS approval. | MTG does not require coverage of all body pain; limited, discrete topography suffices. |
| Was Medical Director’s denial supported by MTG? | Denial misapplied MTG by treating unrelated pain regions as disqualifying. | Denial was consistent because records conceded SCS wouldn’t address all pain. | Denial misapplied guideline language; reversal required. |
| Did claimant meet burden to overturn Medical Director? | Satisfied criteria for SCS trial for L5 radiculopathy and submitted supporting records. | Claimant failed to show by clear and convincing evidence the Medical Director was wrong. | Court reversed despite standard, finding misinterpretation of guideline. |
| Would allowing targeted SCS conflict with MWCA purpose? | Targeted non-narcotic treatment aligns with MWCA’s goal of returning workers and providing necessary care. | (Implicit) Restricting SCS prevents unnecessary procedures. | Court recognized policy favoring appropriate non-narcotic treatment. |
Key Cases Cited
- Church Mutual Ins. Co. v. Louisiana Workforce Commission, 145 So.3d 271 (La. 2014) (summarizes Medical Treatment Guidelines and statutory framework for preauthorization and appeals)
- Pumphrey v. City of New Orleans, 925 So.2d 1202 (La. 2006) (principle that clear statutory language controls interpretation)
- Champagne v. American Alternative Ins. Corp., 112 So.3d 179 (La. 2013) (description of workers’ compensation act as quid pro quo and guidance on statutory purpose)