Opinion ID: 2502398
Heading Depth: 1
Heading Rank: 4

Heading: Initial Psychiatric Consultation

Text: The claims administrator denied Mr. Hale's request to add depression to his claim, in part, because Rule 20 indicates that the initial (psychiatric) evaluation and subsequent treatment must be authorized by the employer. In making this determination, the claims administrator relied on W.Va.C.S.R. § 85-20-12.5, which provides, in relevant part: 12.5 Treatment guidelines. Treatment of mental conditions to injured workers is to be goal directed, time limited, intensive, and limited to conditions caused or aggravated by the industrial condition. a. Initial evaluation and subsequent treatment must be authorized by Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable[.] While this regulation states that a claimant must get prior authorization before seeking an initial psychiatric consultation, W.Va.C.S.R. § 85-20-9.10(g) expressly exempts a claimant from getting prior authorization for an initial psychiatric consultation: 9.10 The following services require prior review and authorization before services are rendered and reimbursement made: g. Psychiatric treatment (does not include the initial psychiatric consultation)[.] This issue requires us to interpret two conflicting regulations contained in Rule 20. To be valid, a regulation promulgated by an administrative agency must carry out the legislative intent of its governing statutes. In Syllabus Point 3 of Rowe v. W.Va. Dep't of Corr., 170 W.Va. 230, 292 S.E.2d 650 (1982), this Court held: It is fundamental law that the Legislature may delegate to an administrative agency the power to make rules and regulations to implement the statute under which the agency functions. In exercising that power, however, an administrative agency may not issue a regulation which is inconsistent with, or which alters or limits its statutory authority. In the case sub judice, we have two regulations, W.Va.C.S.R. § 85-20-12.5(a) and W.Va.C.S.R. § 85-20-9.10(g), that are in direct conflict with each other. In order to resolve this conflict, we first look to a corresponding regulation contained in Rule 20, W.Va.C.S.R. § 85-20-12.4 [2005], which sets forth the process a claimant must follow to add a psychiatric condition to his/her claim. W.Va.C.S.R. § 85-20-12.4 states: Compensability. Services may be approved to treat psychiatric problems only if they are a direct result of a compensable injury. As a prerequisite to coverage, the treating physician of record must send the injured worker for a consultation with a psychiatrist who shall examine the injured worker to determine 1) if a psychiatric problem exists; 2) whether the problem is directly related to the compensable condition; and 3) if so, the specific facts, circumstances, and other authorities relied upon to determine the causal relationship. The psychiatrist shall provide this information, and all other information required in section 8.1 of this Rule in his or her report. . . Based on that report, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will make a determination, in its sole discretion, whether the psychiatric condition is a consequence that flows directly from the compensable injury. (Emphasis added). W.Va.C.S.R. § 85-20-12.4 can be distilled into a three-step process. First, a claimant's treating physician is to refer the claimant to a psychiatrist. The second step is for the psychiatrist to examine the claimant and make a detailed report consistent with the procedure described in section 12.4. The third step is for the claims administrator to review the psychiatrist's report and determine whether the psychiatric condition should be added as a compensable injury of the claim. The three-step process in section 12.4 is inconsistent with section 12.5(a), which states that the initial psychiatric evaluation must be authorized by the claims administrator. Section 12.5(a) does not set forth any criteria a claims administrator should use to determine whether an initial psychiatric consultation should be approved. Unlike the three-step process in section 12.4, which utilizes expert medical and psychiatric professionals who make their determinations after directly examining a claimant, section 12.5(a) requires the claims administrator to make a psychiatric treatment decision without having a medical report from the treating physician or a psychiatric report from a psychiatrist who has seen the claimant. Instead, 12.5(a) requires the claims administrator to make this determination based only on a request from the claimant. [5] This Court has held that [p]rocedures and rules properly promulgated by an administrative agency with authority to enforce a law will be upheld so long as they are reasonable and do not enlarge, amend or repeal substantive rights created by statute. Syllabus Point 4, State ex rel. Callaghan v. W.Va. Civil Serv. Comm'n, 166 W.Va. 117, 273 S.E.2d 72 (1980). We find that W.Va.C.S.R. § 85-20-12.5(a) is not a reasonable rule because it requires a claims administrator to make a psychiatric treatment decision without having the benefit of expert medical and psychiatric opinions on which to base this treatment decision. Because a claims administrator can deny psychiatric treatment before a claimant has the opportunity to see a psychiatric professional, we find that W.Va.C.S.R. § 85-20-12.5(a) does not comport with the express legislative intent set forth in the workers' compensation statutory lawit does not fulfill the Legislature's goal of compensating injured workers for injuries they have sustained in the course of and resulting from their . . . employment. W.Va.Code § 23-4-1(a)[2008]. As opposed to section 12.5(a), W.Va.C.S.R. § 85-20-9.10(g) is consistent with the three-step process contained in section 12.4 and with the Legislature's goal of compensating workers for injuries sustained in the course of their employment. W.Va.C.S.R. § 85-20-9.10(g) exempts a claimant from getting prior authorization from the claims administrator before seeking an initial psychiatric consultation. This exemption stated in section 9.10(g) is consistent with section 12.4, which requires a claimant's treating physician, not the claims administrator, to make the referral for an initial psychiatric consultation. The policy reasons underlying sections 9.10(g) and 12.4 are compelling. A treating physician has the opportunity to personally treat and observe a claimant and can therefore make an informed decision on whether a referral for an initial psychiatric consultation is warranted. Sections 9.10(g) and 12.4 also promote expedited treatment for a claimant experiencing psychiatric problems because the treating physician can make an immediate referral to a psychiatrist, whereas under section 12.5(a), a claimant must apply to the claims administrator and wait for the request to be processed and ruled upon before the three-step process outlined in 12.4 can begin. Based on all of the foregoing, we hold that W.Va.C.S.R. § 85-20-12.5(a) [2005] is an invalid administrative rule because it is in direct conflict with W.Va.C.S.R. § 85-20-9.10(g) [2005] and W.Va.Code § 23-4-1(a)[2008], and because it requires the claims administrator to make a psychiatric treatment decision without having the benefit of an expert psychiatric report, as required by W.Va.C.S.R. § 85-20-12.4 [2005]. We also hold that W.Va.C.S.R. § 85-20-12.4 [2005] sets forth the following three-step process that must be followed when a claimant is seeking to add a psychiatric disorder as a compensable injury in his/her workers' compensation claim: (1) the claimant's treating physician refers the claimant to a psychiatrist for an initial consultation; (2) following the initial psychiatric consultation, the psychiatrist is to make a detailed report consistent with the procedure described in W.Va.C.S.R. § 85-20-12.4 [2005]; and (3) the claims administrator, aided by the psychiatrist's report, is to determine whether the psychiatric condition should be added as a compensable injury in the claim. Applying these holdings to the facts of this case, we conclude that the three-step process outlined in W.Va.C.S.R. § 85-20-12.4 was not followed. The claims administrator failed to follow the procedure in section 12.4 and neither the OOJ, nor the BOR order affirming the OOJ, discussed the three-step process that must be followed when a claimant seeks to add a psychiatric condition to his/her claim. Because of our holding that W.Va.C.S.R. § 85-20-12.5(a) is an invalid administrative regulation, and our finding that Mr. Hale did not receive the process that he was entitled to under W.Va.C.S.R. § 85-20-12.4, we reverse the BOR's August 9, 2010, order and remand this matter to the BOR for entry of an order directing that Mr. Hale be seen by a psychiatrist for an initial evaluation. [6]