Court Opinion

ID: 9949608
Source: CourtListenerOpinion
Date Created: 2024-03-12 12:46:20.069816+00
Date Added: 2024-06-11T14:29:18.711988
License: Public Domain

FILED
                                                                                                   Mar 08, 2024
                                                                                                   02:55 PM(ET)
                                                                                             TENNESSEE COURT OF
                                                                                            WORKERS' COMPENSATION
                                                                                                   CLAIMS

                TENNESSEE BUREAU OF WORKERS’ COMPENSATION
               IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
                                AT KNOXVILLE

    TORIBA ALVAREZ,                                     )   Docket No. 2019-03-1529
             Employee,                                  )
    v.                                                  )
    LFC ENTERPRISES, INC.,                              )   State File No. 17046-2019
             Employer.                                  )
    And                                                 )
    TRAVELERS,                                          )   Judge Lisa A. Lowe
             Carrier.                                   )

                  EXPEDITED HEARING ORDER GRANTING BENEFITS

        LFC Enterprises accepted Ms. Alvarez’s left-ankle injury as compensable and
authorized treatment. The current issue involves approval of either a nerve block or a nerve
stimulator implant trial ordered by pain management. LFC denied the treatment based on
utilization review. After a March 6, 2024 hearing, the Court holds that Ms. Alvarez is
likely to prevail at a hearing on the merits on entitlement to a nerve block.

                                             History of Claim

       In February 2019, Ms. Alvarez sustained a left-ankle injury while working. She
received conservative orthopedic treatment. Ultimately the orthopedist placed her at
maximum medical improvement and assigned a 3% impairment rating. However, because
of continued pain, Ms. Alvarez also received authorized pain management treatment.

        During pain management, she underwent two nerve blocks in her ankle, which did
not help much. Then she had a peripheral nerve block1, which provided significant
improvement. Her pain level went from a 7 or 8 to a 2 or 3, and she reported 80% pain
relief for three months before the pain gradually reoccurred.

          Based on the improvement, pain management ordered another peripheral nerve

1
    Ms. Alvarez’s son testified the peripheral nerve block was given in Ms. Alvarez’s shin area.
                                                       1
block noting:

       This is probably the least invasive and least inconvenient for intervention . .
       . as opposed to a peripheral nerve stimulator trial and implantation. . . . It’s
       worth noting [she] is not receiving any type of continuous daily opioid
       therapy, so the only means of pain relief and improvement in her quality of
       life is this peripheral nerve block.

      LFC did not approve the peripheral nerve block. Pain management again wrote that
Ms. Alvarez had excellent results from the last peripheral nerve block, and she needed
another injection to manage her nerve injury symptoms.

       LFC sent the order to utilization review. The reviewer denied the nerve block
because Ms. Alvarez’s pain returned after the first nerve block and limited information was
provided regarding other failed conservative treatment measures. In response, pain
management outlined in the treatment notes conservative care measures that Ms. Alvarez
treated with a boot, physical therapy, steroid shots, and medications. Further, pain
management noted, “her pain remains virtually untreated due to the continued denial of
care by the workers’ compensation carrier.”

        Pain management continued to recommend the peripheral nerve block, and LFC
continued to deny authorization. Finally, pain management offered a peripheral nerve
stimulator trial and implant if successful. They noted that procedure is more invasive and
costly, but an option since LFC would not approve the nerve block.

        Ultimately pain management submitted an order for the nerve stimulator trial and
wrote that “workers’ compensation continues to deny services to this minority female
Hispanic injured worker based on an unknown set of guidelines.” LFC sent the order to
utilization review, which denied the treatment because “there is insufficient evidence to
support the safety and effectiveness and no documentation of exceptional factors.”

                        Findings of Fact and Conclusions of Law

        Ms. Alvarez must prove a likelihood of prevailing at a hearing on the merits that she
is entitled to the requested benefits. Tenn. Code Ann. § 50-6-239(d)(1) (2023); McCord v.
Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar.
27, 2015).

       Tennessee Code Annotated section 50-6-204(a)(1)(A) states that an employer shall
furnish, free of charge to the employee, “treatment . . . made reasonably necessary” by the
work accident. Under section 50-6-204(a)(3)(H), any treatment recommended by a
physician under this subdivision (a)(3) or by referral, shall be presumed to be medically
necessary for treatment.

                                              2
       To determine medical benefits in this case, the Court must weigh the opinions of the
authorized pain management provider and the utilization review physicians.

        The utilization review physician denied the peripheral nerve block because the pain
relief did not last long and limited information on other conservative measures. However,
the utilization review physician reviewed the pain management records and included in his
report that Ms. Alvarez had bracing, steroid injections, medications, and the ankle nerve
blocks. He additionally noted that Ms. Alvarez had an 80% pain reduction that lasted three
months.

       Pain management treatment recommendations are presumed reasonable and
necessary. Additionally, pain management routinely outlined in its notes the conservative
treatment Ms. Alvarez tried and failed, the relief she had from the peripheral nerve block,
and the fact that the repeated denials by the carrier has left her with no treatment at all for
her work-related nerve pain. The pain management notes clearly describe in detail why
the peripheral nerve block is warranted. Further, pain management only ordered the
peripheral nerve stimulator, a more costly and invasive treatment, because LFC would not
authorize the peripheral nerve block. But LFC denied that treatment as well.

      The Court gives greater weight to the opinions of the pain management provider
and holds that Ms. Alvarez is likely to prevail on entitlement to the peripheral nerve block.

IT IS, THEREFORE, ORDERED as follows:

   1. LFC Enterprises, Inc. shall provide medical care for Ms. Alvarez’s injuries as
      required by Tennessee Code Annotated section 50-6-204 including, but not limited
      to, authorizing the ordered peripheral nerve block.

   2. The Court sets a Scheduling Hearing on June 7, 2024, at 9:30 a.m. Eastern Time.
      The parties must call 865-594-0109 or 855-383-0003 to participate.

   3. Unless interlocutory appeal of this Expedited Hearing Order is filed, compliance
      with this Order must occur by seven business days of entry of this Order as required
      by Tennessee Code Annotated section 50-6-239(d)(3). The Insurer or Self-Insured
      Employer must submit confirmation of compliance by email to
      WCCompliance.Program@tn.gov by the compliance deadline. Failure to do so may
      result in a penalty assessment for non-compliance.

   4. For compliance questions, please contact the Workers’ Compensation Compliance
      Unit by email at WCCompliance.Program@tn.gov

   ENTERED on March 8, 2024.

                                              3
                                _____________________________________
                                JUDGE LISA A. LOWE
                                Court of Workers’ Compensation Claims

                                    APPENDIX

Exhibits:

   1. Rule 72 Declaration of Toriba Alvarez, December 11, 2023
   2. Medical Records of Associated Pain Specialists
   3. Utilization Review Denial, March 30, 2023
   4. Utilization Review Denial, October 25, 2023

Technical Record:

   1. Petition for Benefit Determination
   2. Hearing Request, December 8, 2021
   3. Rule 72 Declaration of Toriba Alvarez, interpreted December 20, 2021
   4. Expedited Hearing Order Granting in Part and Denying in Part
   5. Dispute Certification Notice, June 20, 2023
   6. Notice of Filing Wage Statement
   7. Hearing Request, December 11, 2023
   8. Employer’s Expedited Hearing Pre-Trial Brief
   9. Employer’s Exhibit List
   10. Employer’s Notice of Filing Medical Records Table of Contents
   11. Employer’s Witness List

                                          4
                         CERTIFICATE OF SERVICE

    I certify that a copy of the Order was sent as indicated on March 8, 2024.

        Name               Mail      Email      Service sent to:
Toriba Alvarez              X         X         1749 Louisiana Avenue
Employee                                        Knoxville, TN 37921
                                                Christian.hardscapes01@gmail.com

Jennifer C. Schmidt                     X       JSCHMID@travelers.com
Employer’s Attorney

                                       _____________________________________
                                       PENNY SHRUM, Court Clerk
                                       WC.CourtClerk@tn.gov

                                            5
                                              NOTICE OF APPEAL
                                      Tennessee Bureau of Workers’ Compensation
                                        www.tn.gov/workforce/injuries-at-work/
                                        wc.courtclerk@tn.gov | 1-800-332-2667

                                                                                  Docket No.: ________________________

                                                                                  State File No.: ______________________

                                                                                  Date of Injury: _____________________

         ___________________________________________________________________________
         Employee

         v.

         ___________________________________________________________________________
         Employer

Notice is given that ____________________________________________________________________
                         [List name(s) of all appealing party(ies). Use separate sheet if necessary.]

appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the
Workers’ Compensation Appeals Board (check one or more applicable boxes and include the date file-
stamped on the first page of the order(s) being appealed):

□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________
□ Compensation Order filed on__________________ □ Other Order filed on_____________________
issued by Judge _________________________________________________________________________.

Statement of the Issues on Appeal
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Parties
Appellant(s) (Requesting Party): _________________________________________ ☐Employer ☐Employee
Address: ________________________________________________________ Phone: ___________________
Email: __________________________________________________________
Attorney’s Name: ______________________________________________ BPR#: _______________________
Attorney’s Email: ______________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
                           * Attach an additional sheet for each additional Appellant *

LB-1099 rev. 01/20                              Page 1 of 2                                              RDA 11082
Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________

Appellee(s) (Opposing Party): ___________________________________________ ☐Employer ☐Employee
Appellee’s Address: ______________________________________________ Phone: ____________________
Email: _________________________________________________________
Attorney’s Name: _____________________________________________ BPR#: ________________________
Attorney’s Email: _____________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
                              * Attach an additional sheet for each additional Appellee *

                                             CERTIFICATE OF SERVICE

I, _____________________________________________________________, certify that I have forwarded a
true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described
in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this
case on this the __________ day of ___________________________________, 20 ____.

                                                           ______________________________________________
                                                            [Signature of appellant or attorney for appellant]

LB-1099 rev. 01/20                                 Page 2 of 2                                        RDA 11082