Flyin’ High………. And the Role of Utilization Review in a Delaware Drug Diversion Case

Flyin’ High………. And the Role of Utilization Review in a Delaware Drug Diversion Case

Today’s case comes to us by way of Marshall Dennehy’s Jessica Julian.  That is Jess and her family pictured here.  What tickles me about this picture, pilfered from Facebook, is that these are some seriously beautiful people.  And if “beauty” can be considered a generational curse, then these people are doomed…….:>)

I knew about this case before it went to a Legal Hearing because Jess was obsessing about it. I respect Jess’ anal-retentiveness, as it is a quality I cherish in myself.  And I have been there.  The whole “I am so certain of the correctness of my position and it is so glaringly clear and unambiguous to me………… so what am I missing?”  And in this case Jess didn’t miss a thing.

The case is Nathaniel Brandon v. State of Delaware, IAB#1372970 (4/4/14)(ORDER).

And here is the issue in a nutshell-
If the employer wants to deny approval for medications based on the proposition that claimant is selling them on the street,  what is that exactly—is it a causation denial, a reasonableness and necessity denial, does it go to UR…. or what?

The claimant convened a Legal Hearing to compel an Order for the State to continue to pay for his Oxy.  Which was kind of audacious of him given that he was arrested for selling the Oxy (don’t you just hate it when that happens?).  The State’s position was that, since the claimant was selling the medication the State was providing for the work accident, one could fairly conclude that he doesn’t need it.  The State thus considered this a “causation” denial.  As such, the denial was not based on a UR referral, since UR does not address medical treatment where there is a causation challenge (and in fact a UR referral waives causation).

Interestingly the Board found this to be a “gray” area and by that I infer that the treatment could have gone for UR based on it being perceived to be unreasonable and unnecessary or it could be denied based on the State’s position that if claimant isn’t taking the medication, he doesn’t need the medication—ergo, there is a lack of causation. I am a bit confused personally regarding the proposition that this issue could have been submitted to UR as the IAB ruling suggests—based on my own understanding that UR would have only looked at whether the issuance of the script for these medications was within the Practice Guidelines and would have done absolutely nothing with any behavior of the claimant beyond that.  If any of you know differently, please clue me in and I will be happy to correct any misapprehensions in a future post.

The Motion to Compel was denied.  Claimant was instructed to file a DACD Petition seeking payment of his medications.

Good luck with that.

Irreverently yours,

 

 

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