West Virginia Supreme Court Continues Trend of Weakening Medical Management Guidelines

West Virginia Supreme Court Continues Trend of Weakening Medical Management Guidelines

H. Dill Battle, III By H. Dill Battle, III

In a new reported decision the West Virginia Supreme Court of Appeals addressed the addition of psychiatric diagnoses as a secondary condition to a compensable injury.

In Hale v. WVOIC and Rockspring Development, Inc., No. 101028, (W. Va. March 22, 2012), the Court continues its recent trend of weakening the Rule 20 medical management guidelines. The Court addressed whether a claimant must get prior authorization from a claims administrator before seeking an initial psychiatric consultation.

In an unanimous opinion, the Court held that W. Va. C.S.R. § 85-20-12.5(a) was invalid because it is in direct conflict with W. Va. C.S.R. § 85-20-9.10(g) and W. Va. Code § 23-4-1(a), 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. Hale at 10-11.

The Court provided a roadmap for claims administrators when it held that W. Va. C.S.R. § 85-20-12.4 sets forth a 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; 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. Hale, at 10-11.

It is a pragmatic decision based on the facts of the case although it seems like a relatively light burden for a treating doctor who suspects a psychiatric consequence to seek authorization for a consultation. In that sense it is no different than asking for a neurosurgical or orthopedic referral. However, carriers, self-insured employers, and claims administrators are still allowed to make the ultimate decision about whether to add the psychiatric diagnosis aided by detailed psychiatrist's report.

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