AT&T Communications and Sedgwick CMS v. Victoria Murray Rosso
Opinion Filed: May 2, 2017
Date of Accident: February 10, 1989
Keywords: medical necessity, physicians, nurse; home renovations
Rule: A determination of medical necessity must be made by a physician.
Summary: Claimant sustained a compensable injury to her lower back. After undergoing spinal fusion surgery the Claimant had trouble walking and standing without falling. Claimant petitioned for and was awarded by the JCC: authorization of lawn care, attendant care for at least four hours, evaluation and treatment by a podiatrist, custom AFO brace, and home renovations. A registered nurse with rehabilitation experience and training prepared a home assessment for Claimant. The assessment recommended home renovations including ramp access, outdoor motion sensor lighting, The Court reversed the award for home renovations. The physicians deferred to the nurse’s assessment with respect to medical necessity. However, the nurse’s opinion was insufficient to establish medical necessity because she is not a physician. Furthermore, the physicians did not specify which renovations they agreed with along with the rationale for medical necessity.
Pedro Leon v. CSB Services, Inc. North American Risk Services, Inc. Sea Bright Insurance
Date of Accident:
OJCC Case: 00-027634GCC
Keywords: due process; medical necessity; sua sponte
Rule: A JCC’s sua sponte denial of a claim based on a defense not raised by the Employer/Carrier is a violation of Claimant’s right to due process.
Summary: Claimant sustained a workplace injury in 2000. In 2002, he achieved maximum medical improvement (MMI) with a permanent impairment rating. Claimant later moved to Peru where Dr. Linares was authorized by the Employer/Carrier. Dr. Linares was hostile to the Florida workers’ compensation system and was “unwilling to treat” Claimant. Afterwards, Claimant filed a PFB seeking authorization of an orthopedist to replace Dr. Linares.” Employer/Carrier argued that Dr. Linares was still treating Claimant. JCC rejected this argument and sua sponte ruled in Employer/Carrier’s favor based on medical necessity. The Court reversed the JCC, holding that a JCC violates a Claimant’s right to due process when it denies sua sponte a claim based on a defense not raised by the Employer/Carrier. Since Employer/Carrier had never raised medical necessity as a defense, the JCC erred in deciding the case on medical necessity.