Case Title: Ex parte Larry E. Bolton. PETITION FOR WRIT OF CERTIORARI TO THE COURT OF CIVIL APPEALS (In re: James River Corporation v. Larry E. Bolton) (Mobile Circuit Court: CV-94-3859.51; Civil Appeals : 2060675). WRIT DENIED. NO OPINION.

Citation: 

Docket Number: 1071521

State: alabama

Court: Alabama Supreme Court

Date: 2009-02-27T00:00:00Z

Document:
REL:2/27/2009
Notice: This opinion is subject to formal revision before publication in the advance
sheets of Southern Reporter.  Readers are requested to notify the Reporter of Decisions,
Alabama Appellate Courts, 300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334) 229-
0649), of any typographical or other errors, in order that corrections may be made before
the opinion is printed in Southern Reporter.
SUPREME COURT OF ALABAMA
OCTOBER TERM, 2008-2009
____________________
1071521
____________________
Ex parte Larry E. Bolton
PETITION FOR WRIT OF CERTIORARI
TO THE COURT OF CIVIL APPEALS
(In re: James River Corporation
v.
Larry E. Bolton)
(Mobile Circuit Court, CV-94-3859.51;
Court of Civil Appeals, 2060675)
SMITH, Justice.
WRIT DENIED.  NO OPINION.
Cobb, C.J., and Lyons, Woodall, Stuart, Bolin, Parker,
and Shaw, JJ., concur.  
Murdock, J., concurs specially.
1071521
2
MURDOCK, Justice (concurring specially).
Although I agree with this Court's decision to deny the
petition for a writ of certiorari in this case, I write
separately for two reasons.  
First, I would note that precertification reviews and
utilization reviews are not two separate processes and that a
precertification review is merely one type of utilization
review.  Alabama Admin. Code (Dep't of Indus. Relations), r.
480-5-5-.02(68), defines "utilization review" as "[t]he
determination of medical necessity for surgical in-hospital,
outpatient, and alternative setting treatments for acute and
rehabilitation care."  Rule 480-5-5-.02(60) similarly defines
"pre-certification review" as  "[t]he review and assessment of
the medical necessity and appropriateness of services ...."
The fact that Rule 480-5-5-.02(60) goes on to add that
precertification reviews are reviews of the medical necessity
of services "before [the services] occur" does not mean that
a precertification review is not a utilization review.  The
definition in Rule 480-5-5-.02(68) of "utilization review"
contains no suggestion that that term does not refer to
determinations of medical necessity made before a procedure or
treatment actually occurs; to the contrary, it expressly
1071521
It 
is 
only 
for 
"nonemergency" 
procedures 
that
1
"pre-certification reviews" are even contemplated.  Rule 480-
5-5-.02(68) continues by explaining that, in contrast to such
"pre-certification" reviews, "[c]oncurrent review and, if
necessary, retrospective review are required for emergency
cases."  Moreover, Rule 480-5-5-.02(24) defines "elective
surgery" simply as "surgery which is medically necessary, yet
non-emergency in nature ....." 
3
provides 
that 
a 
"[utilization 
review] 
includes
pre-certification 
for 
elective 
treatments," 
where 
the
reference to "elective treatments" is  a reference to
"nonemergency" treatments.   See also, e.g., Rules 480-5-5-.06
1
and -.07 (explaining that lower levels of  "utilization
review" may provide an "approval of medical services," but
that a higher level of  "utilization review" is required to
"deny a medical service"); Rule 480-5-5-.09 (titled "Procedure
for Pre-Certification" and referencing the applicability of
the second and third levels of clinical review of the
utilization-review 
process 
described 
in 
Rule 
480-5-5-.07); 
and
Rule 
480-5-5-.10 
(providing 
for 
yet 
another 
form 
of
utilization 
review, 
"continued-stay 
review," 
applicable 
to 
the
continuation of hospital stays).  In Ex parte Southeast
Alabama Medical Center, 835 So. 2d 1042, 1051 (Ala. Civ. App.
2002), the Court of Civil Appeals referred to "utilization
1071521
In Ex parte Southeast Alabama Medical Center, the Court
2
of Civil Appeals explained that "the employee's treating
physician ... recommended a particular surgical procedure ...
as medically necessary," but before this nonemergency surgery
was performed, "[t]he employer refused to pay for this
treatment, basing this refusal on the result of its
'utilization review.'" 835 So. 2d at 1059 (emphasis added).
Referring to the regulatory scheme applicable to the
situation, the Court of Civil Appeals explained that the
legislature had "directed the Department of Industrial
Relations to adopt utilization-review procedures for use by
the employer or its insurer, if either elects to conduct
pre-certification reviews." Id. (first and final emphasis
added).
4
review, including precertification of the medical necessity of
various treatments."  (Emphasis added).2
That said, it is clear enough from the facts presented
that the "utilization review" at issue in this case was not a
"precertification," at least not a precertification of the
nature contemplated by Rules 480-5-5-.08 and -.09.  It is the
latter rule, Rule 480-5-5-.09, that contains the notice
provision that the trial court faulted James River Corporation
for not following.  I therefore concur in this Court's denial
of certiorari review.
Second, I write to address the following statement in the
opinion of the Court of Civil Appeals:
"[E]ven 
if 
this 
court 
were 
to 
extend 
the
notification requirements 
of 
precertification 
review
to the utilization-review process, ... it would be
incumbent upon the doctors treating Bolton, as
1071521
5
providers, 
to 
appeal 
the 
denial 
of 
medical
treatment.  The rules governing utilization review
and precertification review grant the right to
appeal an adverse decision only to the provider
treating an injured employee." 
James River Corp. v. Bolton, [Ms. 2060675, February 15, 2008]
___ So. 2d ___, ___ (Ala. Civ. App. 2008).  I offer three
comments on this statement.
First, even if it were "incumbent" on the provider of
medical services to initiate an administrative "appeal" of the
employer's denial, such an appeal would go only to the merits
of the employer's denial –- i.e., whether the requested
medical treatment was reasonably necessary.  The issue in the
present case, however, is whether the failure of the employer
to follow a prescribed notification procedure is a ground for
contempt.  Second, even if the issue in this case was the
substantive one of whether the requested medical treatment was
reasonably necessary, in point of fact I do not see how "it
would [have] be[en] incumbent upon the doctors treating Bolton
... to appeal the denial of medical treatment."  Ex parte
Southeast Alabama Medical Center decided this issue to the
contrary.  835 So. 2d at 1050-63 (holding that employees were
not 
required 
to 
pursue 
or 
exhaust 
utilization-review
procedures and appeals before seeking relief in the circuit
1071521
6
court from an employer's refusal to pay for medical
treatments).  Finally, I note that, although Rules 480-5-5-.08
and -.09 do contemplate that the it will be the employee's
medical provider that requests precertification, the "right"
to such review is the employee's.