But it remains to be seen whether injured workers can actually obtain this type of medical treatment through UR/IMR
In Reese v. All Saints Health Care, 2015 Cal. Wrk. Comp. P.D. LEXIS 570 [2015 Cal. Wrk. Comp. P.D. LEXIS 570], the WCAB rescinded the WCJ’s finding that the applicant licensed vocational nurse who suffered an industrial injury to her lumbar spine, psychological system, central nervous system, and cardiovascular system on 6/16/2002, was not entitled to home health care in the form of housekeeping services, including food preparation, cooking, cleaning, laundry, yard work, shopping, and household chores, as recommended by the primary treating physician Philip A. Sobol, M.D.
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The WCAB rejected the WCJ’s finding that, under Bishop v. W.C.A.B. (2011) 76 Cal. Comp. Cases 1192 [76 CCC 1192] (writ denied), the housekeeping services recommended by Dr. Sobol were not medical treatment as a matter of law. The WCAB concluded instead that pursuant to the decision in Smyers v. W.C.A.B. (1984) 157 Cal. App. 3d 36, 203 Cal. Rptr. 521, 49 Cal. Comp. Cases 454 [49 CCC 454], the expenses for housekeeping services are recoverable as “medical treatment” under Labor Code § 4600 [LC 4600] if the evidence in the case supports a finding that they are reasonable and necessary. Consequently, the applicant’s request for housekeeping services was not precluded.
Although the WCJ correctly found that Dr. Sobol’s opinions were not sufficient to support an award of housekeeping services, the record required further development regarding the applicant’s entitlement to housekeeping services given the application of Smyers and Neri Hernandez v. Geneva Staffing, Inc. (2014) 79 Cal. Comp. Cases 682 [79 CCC 682] (Appeals Board en banc opinion), which had not yet been issued when the parties tried the issue of home care services in this case.
In Reese, the WCJ and panel of WCAB commissioners addressed whether home health care constituted “medical treatment”. Though the commissioners ultimately concluded that home health care could be considered “medical treatment that is reasonably required to cure or relieve the injured worker from the effects of his or her injury” (Labor Code Section 4600(a)), this does not mean that injured workers will be able to obtain this type of medical treatment through the current workers’ compensation process.
Home health care can be multi-faceted. The concept of home health care can include several different types of services to help the injured worker. Home health care can include assistance with food preparation, cooking, cleaning, laundry, household chores, pool cleaning, and even gardening services. In concluding that these additional services could, in fact, constitute medical treatment, the commissioners in Reese relied on the Court of Appeal’s decision in Smyers. Indeed, the Smyers decision held that these additional services could very well constitute reasonable and necessary medical treatment provided that the treating physician has explained why these services were medically necessary.
However, since Smyers was decided in 1984 a great deal has changed in the medical treatment benefit in workers’ compensation. We now have Utilization Review (UR) and independent Medical Review (IMR). Most importantly, all treatment provided in the workers’ compensation system is supposed to be in compliance with specific treatment guidelines. Indeed, Labor Code section 4600(b) provides that “medical treatment that is reasonably required to cure or relieve the injure worker from the effects of his or her injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27”.
Thus, while the commissioners in Reese found that home health care may constitute medical treatment, the more interesting question may be: Had the specific home health care disputed in Reese gone through timely UR and IMR, would Ms. Reese have been able to obtain these services through workers’ compensation? As Ms. Reese suffered from a 2002 date of injury that was subject to a 100% permanent disability award, the medical treatment guidelines adopted by the administrative director for dealing with chronic pain would have been applicable.
The Chronic Pain Medical Treatment Guidelines provide that, in connection with home health services, medical treatment does not include “homemaker services like shopping, cleaning, and laundry, and personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care needed”. While there is a proposed chronic pain medical treatment guideline that will expand the definition of what constitutes appropriate home health care, the guidelines in effect when this dispute was adjudicated would not have provided for this treatment.
Thus, had the current medical treatment benefit system worked as intended in Reese, defendant would have timely placed the issue though UR and UR would have denied the treatment based on the applicable treatment guideline. Applicant would have filed an IMR appeal and IMR would have also denied the treatment.
In conclusion, though the panel of commissioners in Reese may have reasoned that the additional aspects of home health care may constitute medical treatment, it does not mean that the injured worker will actually be able to obtain the treatment.
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