RAFAEL ECHEVARRIA, APPELLANT,
v.
LUXOR INVESTMENTS, LLC AND ASSOCIATED INDUSTRIES INSURANCE COMPANY, APPELLEES

Fla. 1st DCA | 2015-03-18
No. 1D14-3540
LEWIS, C.J. and BENTON, J., concur.
159 So. 3d 991 Florida District Court of Appeal, First District (2015) Positive Treatment
Cited by 1 case

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Synopsis

In this workers' compensation case, the court affirmed the denial of a follow-up neurological appointment for a claimant with compensable workplace injuries. The court held that a permanent impairment rating alone does not automatically entitle a claimant to ongoing palliative treatment without evidence of medical necessity.


Holding

A permanent impairment rating does not automatically entitle a claimant to ongoing palliative care or follow-up medical appointments. Medical necessity for the treatment must be established, defined as treatment appropriate to the patient's diagnosis (the compensable injury), based on competent medical evidence.


Headnotes

[1] A workers' compensation claimant is not entitled to ongoing palliative treatment for a permanent impairment solely based on the impairment rating, absent evidence of medi…

[2] Medical necessity for workers' compensation treatment requires that the treatment be appropriate to the patient's diagnosis, which is the compensable injury.

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Key Quotes

“Neither the relevant statutory provisions within chapter 440, nor our case law, establish such an entitlement in the absence of evidence of medical necessity for the treatment, defined in part as 'appropriate to the patient's diagnosis' — the diagnosis being the compensable injury.”

Establishes the requirement for medical necessity evidence independent of permanent impairment status

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Facts & Procedural History

Claimant suffered compensable workplace injuries and received a permanent impairment rating from his authorized neurologist. He subsequently requested…

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Opinion of the Court
THOMAS, J.

THOMAS, J.

In this workers’ compensation case, Claimant appeals a ruling of the Judge of Compensation Claims (JCC) denying a follow-up appointment with his authorized neurologist for his compensable injuries. The JCC found that the Employer/Carrier met its burden to prove that the compen-sable injuries are not the major contributing cause (MCC) of Claimant’s need for the requested benefit. The JCC further found that “no further neurological treatment is medically necessary in this cause inasmuch as the industrial injuries no longer comprise the MCC for the requested follow-up.”

We affirm. We write only to respond to Claimant’s argument that as a matter of law his permanent impairment rating assigned for his compensable injuries entitle him to ongoing palliative treatment, even in the absence of any medical testimony establishing a need for treatment. Neither the relevant statutory provisions within chapter 440, nor our case law, establish such an entitlement in the absence of evidence of medical necessity for the treatment, defined in part as “appropriate to the patient’s diagnosis” — the diagnosis being the compensable injury. See § 440.13(2)(a), Fla. Stat. (2006) (requiring employer to furnish medically necessary care); § 440.13(1)0), Fla. Stat. (2006) (defining “medical necessity”). Our decision in Homler v. Family Auto Mart, 914 So.2d 1071, 1073 (Fla. 1st DCA 2005), states: “The law is clear that once a claimant establishes a PI [permanent impairment], he or she is entitled to ongoing palliative care for the condition.” But this court also recognized that evidence of medical necessity was present in that case, stating that “the medical testimony and reports reflect *992that claimant has a continuing need for palliative care of her compensable neck injury.” Id. Here, there was no such evidence to establish that Claimant had a medical necessity for palliative treatment.

We acknowledge that some permanent injuries do not require ongoing active treatment but may require periodic doctor visits to ensure that the compensable injury is not worsening or in need of further evaluations or treatment. Nevertheless, here, because Claimant did not establish that either periodic visits or further evaluations by his authorized doctor are appropriate for his compensable workplace injury, we affirm the JCC’s ruling. See Smith v. James Pirtle Constr. Co., 405 So.2d 290, 291 (Fla. 1st DCA 1981) (“Claimant asserts that, as a consequence of having had a compensable permanent impairment, he has an absolute right to a physician’s examination to determine if further medical care, either palliative or remedial, is necessary. We are referred to no such precedent and, absent any evidence from claimant or otherwise, we conclude the deputy correctly denied the motion.”).

AFFIRMED.

LEWIS, C.J. and BENTON, J., concur.


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