Court Opinion

ID: 9386219
Source: CourtListenerOpinion
Date Created: 2023-04-11 17:50:09.499602+00
Date Added: 2024-06-11T17:18:01.387299
License: Public Domain

FILED
                                                                                   Apr 11, 2023
                                                                                   12:43 PM(CT)
                                                                                    TENNESSEE
                                                                               WORKERS' COMPENSATION
                                                                                  APPEALS BOARD

             TENNESSEE BUREAU OF WORKERS’ COMPENSATION
                WORKERS’ COMPENSATION APPEALS BOARD

Peter Rhea                                     )   Docket No.     2022-08-0514
                                               )
v.                                             )   State File No. 50622-2018
                                               )
Titan Transfer, Inc., et al.                   )
                                               )
                                               )
Appeal from the Court of Workers’              )
Compensation Claims                            )
Amber E. Luttrell, Judge                       )

                    Affirmed in Part, Vacated in Part, and Remanded

The employee suffered multiple injuries arising from a work-related accident. During the
course of his medical care, the authorized physician made numerous recommendations that
were subjected to utilization review. Some recommendations were subsequently
authorized following utilization review denials, but others were not. Specifically, the
treating physician recommended a “home gym,” and the employee received home
healthcare that did not necessarily include “nursing services.” Following an expedited
hearing, the trial court conditionally ordered the employer to authorize the installation of a
“home gym.” It also ordered reimbursement for certain home healthcare services already
provided and authorization of additional home healthcare provided by a “nurse, nurse’s
aide, or ‘person whom the medical profession recognizes as a nurse.’” The employer has
appealed. We affirm in part and vacate in part the trial court’s order and remand the case.

Presiding Judge Timothy W. Conner delivered the opinion of the Appeals Board in which
Judge Pele I. Godkin and Judge Meredith B. Weaver joined.

J. Allen Brown, Nashville, Tennessee, for the employer-appellant, Titan Transfer, Inc.

Spencer Barnes, Jackson, Tennessee, for the employee-appellee, Peter Rhea

                           Factual and Procedural Background

       Peter Rhea (“Employee”), a fifty-three-year-old Mississippi resident, worked as a
shop manager and mechanic for Titan Transfer, Inc. (“Employer”), a trucking company.
On June 27, 2018, Employee was gathering tools when a driver backing up a tractor-trailer
struck Employee and pinned him between the truck’s trailer and a tool crib. Employee

                                              1
suffered multiple injuries, including pelvic and femur fractures and nerve injuries resulting
in incontinence. Since the date of the accident, Employee has received care from multiple
providers and is currently under the care of Dr. Michael Beebe, an orthopedic surgeon.

       Employer accepted the accident as compensable and authorized medical care.
However, Employer has submitted certain prescribed treatments to utilization review as
authorized by Tennessee Code Annotated section 50-6-124. Of those prescribed
treatments, some that had been denied as a result of the utilization review process were
appealed to the Medical Director of the Tennessee Bureau of Workers’ Compensation
(“Bureau”). The Medical Director upheld certain denials and overturned others. For
example, on April 29, 2022, the Bureau’s Medical Director overturned utilization review
denials for a fitted knee brace, “bilateral custom AFOs,” 1 wound care, and pain
management. On that same date, the Medical Director agreed with denials for a podiatry
referral, modification of a wheelchair seat, “[l]ifetime aquatic therapy,” “[h]ome gym and
equipment,” a “[h]andicapped vehicle,” “[h]ome ramp modification,” and “[d]aily home
health care.” The Medical Director recommended that Employer authorize a “complete
home environmental evaluation” by a “home specialist.”

       Employee sought an expedited hearing to address the denial of certain
recommendations made by the authorized treating physician. In his brief filed in support
of his expedited hearing request, Employee argued that any recommendation of an
authorized treating physician was entitled to a presumption of medical necessity, and
Employer had failed to provide any evidence overcoming this presumption. In response,
Employer challenged whether “unlicensed sitters, home gymnasiums, home renovations,
vehicle modifications, driving school, furniture, and other similar items” are within the
“breadth and scope of medical benefits.”

       Before the expedited hearing, Employer filed what it called a “Notice of Intent to
Authorize Certain Medical Benefits,” including aquatic therapy, if such therapy can be
arranged pending a medical re-evaluation; a “home safety evaluation”; construction of a
wheelchair ramp, conditioned upon written consent of the home’s owner; a new chair lift;
a modified wheelchair seat; a urology referral; and a neurology referral. 2 Items that
remained at issue included the “home gym” and daily home healthcare services. Following
the expedited hearing, the trial court ordered employer to “provide home gym equipment”
under three conditions: (1) if Employee is deemed unable to operate a modified vehicle; or
(2) if Employer declines to authorize a modified vehicle; and (3) “upon review of the
specialist’s findings from the complete home evaluation.” Moreover, the trial court
ordered Employer to pay an outstanding bill from a company called “Comfort Keepers” in
1
 As explained in Dr. Beebe’s deposition, “custom AFOs” are orthotics intended to help Employee stand
and balance.
2
 Employee rents the home where he resides, and the permission of the homeowner was deemed necessary
before any structural changes could be made.
                                                 2
the amount of $34,461.33, and it ordered Employer to authorize “home health
services . . . with a professional nurse, nurse’s aide, or ‘person whom the medical
profession recognizes as a nurse’ . . . during [Employee’s] wife’s work hours.” Employer
has appealed.

                                        Standard of Review

        The standard we apply in reviewing a trial court’s decision presumes that the court’s
factual findings are correct unless the preponderance of the evidence is otherwise. See
Tenn. Code Ann. § 50-6-239(c)(7) (2022). However, “[n]o similar deference need be
afforded the trial court’s findings based upon documentary evidence.” Goodman v.
Schwarz Paper Co., No. W2016-02594-SC-R3-WC, 2018 Tenn. LEXIS 8, at *6 (Tenn.
Workers’ Comp. Panel Jan. 18, 2018). Similarly, the interpretation and application of
statutes and regulations are questions of law that are reviewed de novo with no presumption
of correctness afforded the trial court’s conclusions. See Mansell v. Bridgestone Firestone
N. Am. Tire, LLC, 417 S.W.3d 393, 399 (Tenn. 2013). We are also mindful of our
obligation to construe the workers’ compensation statutes “fairly, impartially, and in
accordance with basic principles of statutory construction” and in a way that does not favor
either the employee or the employer. Tenn. Code Ann. § 50-6-116 (2022).

                                               Analysis

      Tennessee’s Workers’ Compensation Law states that an employer is required to
provide the following to an employee who suffers a compensable work-related injury:

        such medical and surgical treatment, medicine, medical and surgical
        supplies, crutches, artificial members, and other reasonable and necessary
        apparatus, . . . [and] such nursing services or psychological services as
        ordered by the attending physician . . . made reasonably necessary by
        accident as defined in this chapter.

Tenn. Code Ann. § 50-6-204(a)(1)(A). The scope and breadth of medical treatment as
described in this provision has been the subject of litigation since similar language was
adopted in the original Workers’ Compensation Law in 1919. 3 For example, in Calderon
v. Auto Owners Ins. Co., No. M2015-01707-SC-R3-WC, 2016 Tenn. LEXIS 813 (Tenn.
Workers’ Comp. Panel Oct. 24, 2016), the work injury caused the employee’s paraplegia.
After obtaining a judgment in his favor, the employee later requested that the employer’s
insurer be required to pay the difference between the rent he was paying at the time of the
injury and the rent of a handicap-accessible home. Id. at *3. In rejecting Employee’s
argument that section 204(a)(1)(A) included wheelchair-accessible housing within the

3
 The 1919 Act provided for “such medical and surgical treatment, medicine, medical and surgical supplies,
crutches and apparatus as may be reasonably required.” 1919 Tenn. Pub. Acts, Chap. 123, sec. 25.
                                                   3
meaning of the phrase “other reasonable and necessary apparatus,” the Supreme Court’s
Special Workers’ Compensation Appeals Panel concluded, “the insurer is not responsible
for paying the difference in rent between a non-handicap accessible home and a handicap
accessible home under current law.” Id. at *10. In essence, the Appeals Panel concluded
that such benefits were beyond the scope of “medical benefits” as defined in Tennessee’s
Workers’ Compensation Law. Id. See also Dennis v. Erin Truckways, Ltd., 188 S.W.3d
578, 591 (Tenn. 2006) (“[T]he language of the statute simply cannot sustain the analytical
leap necessary to construe housing as ‘medical apparatus.’ The statute . . . does not
contemplate basic necessities of life, such as housing.”).

       The term “medical treatment” is not defined in Tennessee’s workers’ compensation
statutes and regulations. However, two regulations speak to the scope of medical
treatment. For example, the term “medical necessity” is defined to mean:

        healthcare services that a physician, exercising prudent clinical judgment,
        would provide to a patient for the purpose of preventing, evaluating,
        diagnosing or treating an illness, injury, disease or its symptoms, and that
        are:
        (a)    In accordance with generally accepted standards of medical practice,
               including Treatment Guidelines as defined in Rule 0800-02-06-
               .01(19); 4
        (b)    Clinically appropriate, in terms of type, frequency, extent, site and
               duration; and considered effective for the patient’s illness, injury or
               disease;
        (c)    Not primarily for the convenience of the patient, physician, or other
               healthcare provider; and
        (d)    Not more costly than an alternative service or sequence of services at
               least as likely to produce equivalent therapeutic or diagnostic results
               as to the diagnosis or treatment of that patient's illness, injury or
               disease.

Tenn. Comp. R. & Regs. 0800-02-06-.01(13). In addition, the term “[t]reatment
[g]uidelines” is defined to mean “recommendations intended to optimize patient care that
are informed by a systematic review of the evidence and an assessment of the benefit and
harms of alternative care options.” Tenn. Comp. R. & Regs. 0800-02-06-.01(23). Thus,
for the recommendations of a treating physician to be deemed within the scope of
“reasonable” and “medically necessary” treatment, and therefore compensable under
section 50-6-204(a)(1)(A), it must: (1) comply with generally accepted medical standards;
(2) be clinically appropriate as to type, frequency, extent, site, and duration; (3) not be
primarily for the convenience of the patient or provider; and (4) be the most cost-effective

4
 This cross-reference is in error, as the definition of “Treatment Guidelines” is contained in Tenn. Comp.
R. and Regs. 0800-02-06-.01(23).
                                                    4
alternative among reasonably equivalent alternatives. The statute provides a rebuttable
presumption that treatment recommendations made by an authorized physician are
reasonable and necessary, and the burden is on the employer to establish otherwise by a
preponderance of the evidence. Tenn. Code Ann. § 50-6-204(a)(3)(H).

       Here, Employer did not appeal the trial court’s conditional order for “home gym
equipment”; thus, we need not address this aspect of the trial court’s order. Employer did
appeal: (1) the court’s order for the payment of the past due bill from Comfort Keepers in
the amount of $34,461.33; and (2) the order for ongoing home healthcare services as
provided by a “professional nurse, nurse’s aide, or ‘person whom the medical profession
recognizes as a nurse.’” We elect to address those issues in reverse order.

                                Order for Nursing Services

        As noted above, any treatment recommended by an authorized physician is
presumed to be medically necessary, and the burden of proof in such circumstances shifts
to the employer to prove by a preponderance of the evidence that such prescribed treatment
is not medically necessary. Tenn. Code Ann. § 50-6-204(a)(3)(H); see also Walls v. United
Techs. Corp., No. 2019-05-0371, 2021 TN Wrk. Comp. App. Bd. LEXIS 27, at *10-11
(Tenn. Workers’ Comp. App. Bd. Aug. 6, 2021) (“[I]t is undisputed that the presumption
of medical necessity applied to the surgical recommendations of the authorized physicians,
and the burden fell to Employer to rebut the presumption by a preponderance of the
evidence.”).

        During his deposition, Dr. Beebe described the various diagnoses and medical
conditions caused by the work-related accident. He also explained Employee’s significant
limitations in ambulation caused by several factors, including “equinus contracture” and
“disuse deconditioning of the lower extremities.” With respect to the issue of home
healthcare, Dr. Beebe testified as follows:

      The current function of his lower extremities [is] not such that I would be
      willing to say it would be safe to drive just due to the use of his lower
      extremities. . . . [H]e has a wife who is attempting to work, and he is unable
      to essentially care for himself at home. So, in order to allow him to live
      outside of a care facility, having somebody to assist him with his activities
      of daily living is required. . . . I don’t think he requires it 24 hours a day, but
      I do think he requires it when he doesn’t have somebody at home with him.

(Emphasis added.)

       In Long v. Mid-Tennessee Ford Truck Sales, Inc., 160 S.W.3d 504 (Tenn. 2005),
the Tennessee Supreme Court addressed circumstances in which an injured worker needed
nursing services in his home. In that case, the post-surgical care was provided by the

                                              5
employee’s wife, who was a certified nurse technician. Id. at 507. In describing the care
needed in that case, the Supreme Court explained,

       [Employee] testified that when he went home, he was in a full leg cast, was
       non-ambulatory, and was confined to bed. He was instructed to use a “polar
       pak ice machine” to regulate the temperature of his leg. He testified that the
       ice in the polar pak had to be constantly monitored to ensure that the correct
       temperature was maintained. Shortly after the operation, Long’s wound
       developed a staph infection which took several months to heal. The
       treatment of the infection required that his bandages be changed every four
       hours.

Id. at 507-08. In concluding that the services provided by the employee’s wife were
compensable as nursing services, the Supreme Court explained:

       [A] physician discharging a patient to home, knowing that the patient will be
       confined to a bed and unable to ambulate or perform other functions without
       assistance, and knowing that the patient will require care such as changing
       wound dressings or requiring other such attention, must certainly
       contemplate that nursing services will be required.

Id. at 510.

        In the present case, Dr. Beebe ordered home healthcare and testified why Employee
needed assistance with ambulation and other activities of daily living. The trial court
ordered that, moving forward, Employer authorize such services to be provided by a
nursing professional. Employer offered no evidence that the home healthcare ordered by
Dr. Beebe, an authorized treating physician, was not medically necessary. Therefore, given
that: (1) “nursing services” are expressly included within the scope of medical benefits
contemplated in Tennessee Code annotated section 50-6-204(a)(1)(A); (2) an authorized
treating physician has prescribed such services; and (3) Employer has not met its burden
of proving by a preponderance of the evidence that such nursing services are not medically
necessary, we have no difficulty affirming that aspect of the trial court’s order.

       Further, Employer asserts on appeal that the trial court failed to specify a duration
for home healthcare services. The answer to that question is found in the pertinent statutory
provisions and applicable regulations. The treatment must be provided as long as it is
“made reasonably necessary” by the work accident, see Tennessee Code Annotated section
50-6-204(a)(1)(A), and as long as it satisfies the criteria of Tenn. Comp. R. and Regs. 0800-
02-06-.01(13).

                                             6
                            Payment of Past Home Healthcare Services

       More difficult is the issue concerning the past invoices from Comfort Keepers
totaling $34,461.33. Employee testified without contradiction that he never ordered or
signed a contract for the caregivers provided by Comfort Keepers, and he was never made
aware of the licensure status of the caregivers provided by Comfort Keepers. 5 Employee
also argued that Employer or its insurer had authorized and paid Comfort Keepers to
provide caregivers in Employee’s home for several years without any issues being raised.

        On the other hand, Employer produced some evidence that at least two of the
caregivers assigned by Comfort Keepers to care for Employee were not licensed or certified
nursing professionals. 6 Missing from the record, however, is any evidence that Employer
or its insurer “de-authorized” Comfort Keepers in writing or otherwise put them on notice
that it would no longer authorize the services provided to Employee by Comfort Keepers.
Also missing from the record is any evidence that Employer informed Employee that
services provided by Comfort Keepers were no longer authorized. The evidence included
in the record indicates that Comfort Keepers provided home assistance services for a
significant period of time after Employer stopped paying, but it remains unclear why. 7

       Tennessee Code Annotated section 50-6-122(b) addresses such circumstances.
Generally, a healthcare provider cannot pursue payment from an employee for non-
emergency healthcare services unless: (1) the injury is adjudicated to be not compensable;
(2) the provider knew it was not authorized by the employer to provide the services at the
time the services were rendered; or (3) the employee knew that the provider was not
authorized by the employer to provide care. Thus, the issue of notice is important to this
analysis. If Employer put Comfort Keepers on notice that its services were no longer
authorized, and Comfort Keepers continued to provide services without entering into a
contract with Employee, such circumstances could impact Employer’s liability for
payment of those invoices. Moreover, if the services provided by Comfort Keepers were
unauthorized and Employee was aware of this, Employee must establish it was reasonable
and necessary for him to obtain those services despite Employer’s decision not to authorize

5
  Employer argued that the evidence suggested that Employee must have entered into a contract with
Comfort Keepers given the length of time such services were provided after Employer (or its insurer)
stopped paying the invoices. We reach no conclusion regarding this issue given the lack of evidence
supporting the existence or non-existence of such a contract.
6
 As explained by the trial court, such providers may include a professional nurse (R.N., L.P.N), a certified
nursing aide, or “a person whom the medical profession recognizes as a nurse.” See Sullivan v. Edwards
Oil Co., 141 S.W.3d 544, 549 (Tenn. 2004). Moreover, as explained by the Supreme Court in Long, it may
also include a “certified nurse technician.” Long, 160 S.W.3d at 507.
7
  Although the parties attempted to obtain a transcript of the hearing, the poor sound quality of the recording
made it impossible to provide a transcript. The joint statement of the evidence did not summarize any
testimony addressing this issue.
                                                      7
the care. See, e.g., Barrett v. Lithko Contracting, Inc., Nos. 2015-06-0186, 2015-06-0188,
2015-06-0189, 2016 TN Wrk. Comp. App. Bd. LEXIS 93, at *7 (Tenn. Workers’ Comp.
App. Bd. Dec. 8, 2016) (“an employer who elects to deny a claim runs the risk that it will
be held responsible for medical benefits obtained from a medical provider of the
employee’s choice”).

       Thus, the communications between Employee and Employer, if any, regarding the
continued use of the services of Comfort Keepers, as well as any notification to Comfort
Keepers that their services were no longer authorized, could impact the analysis of
Employer’s liability for these past bills. As a result, we are compelled to vacate the portion
of the trial court’s order requiring Employer (or its insurer) to pay past invoices from
Comfort Keepers until such time as additional evidence is received regarding the issue of
notice (or lack thereof) and the reasonableness and necessity of such services provided by
Comfort Keepers under the circumstances.

                                        Conclusion

        For the foregoing reasons, we affirm the portion of the trial court’s order compelling
Employer to authorize and pay for home healthcare services provided by a licensed or
certified nursing professional. We vacate the portion of the trial court’s order compelling
Employer to pay past invoices of Comfort Keepers, and we remand the case for the court
to consider any additional evidence the parties may wish to present regarding notice of the
de-authorization of Comfort Keepers and the reasonableness and necessity of such services
as discussed above. Costs on appeal are taxed to Employer.

                                              8
                  TENNESSEE BUREAU OF WORKERS’ COMPENSATION
                    WORKERS’ COMPENSATION APPEALS BOARD

Peter Rhea                                                   )         Docket No. 2022-08-0514
                                                             )
v.                                                           )         State File No. 50622-2018
                                                             )
Titan Transfer, Inc., et al.                                 )
                                                             )
                                                             )
Appeal from the Court of Workers’                            )
Compensation Claims                                          )
Amber E. Luttrell, Judge                                     )

                                      CERTIFICATE OF SERVICE

I hereby certify that a true and correct copy of the Appeals Board’s decision in the referenced
case was sent to the following recipients by the following methods of service on this the 11th day
of April, 2023.

 Name                              Certified   First Class       Via    Via     Sent to:
                                   Mail        Mail              Fax    Email
 J. Allen Brown                                                           X     allen@jallenbrownpllc.com
 Spencer Barnes                                                           X     spence@morrisonandbarnes.com
                                                                                mbwcparalegal@morrisonandbarnes.com
 Amber E Luttrell, Judge                                                  X     Via Electronic Mail
 Kenneth M. Switzer, Chief Judge                                          X     Via Electronic Mail
 Penny Shrum, Clerk, Court of                                             X     penny.patterson-shrum@tn.gov
 Workers’ Compensation Claims

Olivia Yearwood
Clerk, Workers’ Compensation Appeals Board
220 French Landing Dr., Ste. 1-B
Nashville, TN 37243
Telephone: 615-253-1606
Electronic Mail: WCAppeals.Clerk@tn.gov