Gilliam v. Brooks Heating & Air Conditioning
146 So. 3d 734
| La. Ct. App. | 2014Background
- On May 3, 2012 Daryl Gilliam injured his low back at work after falling from a ladder; MRI showed multilevel degenerative changes and broad-based central herniation at L1-2 with additional bulges at L2-3, L3-4, L4-5.
- Treating neurosurgeon Dr. Ramos recommended a minimally invasive multilevel (L1-2 through L4-5) right laminectomy/microdiscectomy after failed conservative measures and progressive symptoms (including new urinary incontinence).
- Employer’s utilization reviewer (Novare) denied authorization; employer-obtained second opinion (Dr. Smith) concluded surgery was not indicated and emphasized chronic degenerative disease and need for rehabilitation.
- Medical Director denied the requested four-level surgery under the Medical Treatment Guidelines (MTG) for lack of specific correlation between clinical findings and imaging at each operative level.
- Gilliam appealed to the Workers’ Compensation Judge (WCJ), which considered additional evidence (Dr. Ramos’s deposition and Dr. Smith’s report not previously reviewed by the Medical Director) and affirmed the Medical Director; Gilliam appealed.
- Court affirmed: claimant failed to prove by clear and convincing evidence that the Medical Director misapplied the MTG; claimant may seek a new request in the future given later MTG revisions.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether WCJ may consider medical evidence not reviewed by the Medical Director | WCJ should be able to consider Dr. Ramos’s deposition and Dr. Smith’s report submitted at hearing | Medical Director’s decision should limit judicial review to the record considered by the Medical Director | WCJ may consider additional evidence; not bound to exclude evidence not before Medical Director |
| Standard of proof to overturn Medical Director under MTG | Gilliam: Medical Director erred; treating physician shows surgery is needed | Employer: Medical Director followed MTG; claimant must prove by clear and convincing evidence | To overturn, claimant must prove by clear and convincing evidence; Gilliam failed to meet that burden |
| Whether requested multilevel surgery met MTG correlation requirement (clinical findings ↔ imaging) | Dr. Ramos: MRI shows central herniations affecting bilateral roots; clinical radiculopathy and deterioration justify decompression at multiple levels | Medical Director/Dr. Smith: imaging does not show compressive pathology at all requested levels; correlation lacking for four-level procedure | Court held Medical Director properly required level-by-level correlation; four-level procedure was not shown to meet MTG criteria |
| Whether non-surgical care was exhausted and expected functional outcome justifies surgery | Gilliam: tried PT but worsened; progressive deficits (including incontinence) and lack of improvement support surgery | Employer: claimant did not complete an adequate trial of conservative care; surgery unlikely to restore heavy-lift capacity; conservative rehab indicated | Court gave weight to failure to complete/coordinate adequate non-surgical rehab and to MTG directive to consider functional outcome; surgery denial upheld |
Key Cases Cited
- Church Mut. Ins. Co. v. Bardar, 145 So.3d 271 (La. 2014) (discusses MTG effect on burden of proof and medical necessity under La. R.S. 23:1203.1)
- Stobart v. State through Dep’t of Transp. & Dev., 617 So.2d 880 (La. 1993) (standard for manifest error review of factual findings)
- Banks v. Industrial Roofing & Sheet Metal Works, Inc., 696 So.2d 551 (La. 1997) (factual-review principles in workers’ compensation context)
- Hatcherson v. Diebold, Inc., 784 So.2d 1284 (La. 2001) (explains "clear and convincing" intermediate evidentiary standard)
- Daniels v. State through Dep’t of Transp. & Dev., 144 So.3d 1123 (La. App. 2d Cir. 2014) (permitting WCJ consideration of additional evidence in MTG disputes)