Morgan’s Tip of the Week – MCC and Specific Diagnosis

Greetings, the 1st DCA issued a ruling last week clarifying-ish Major Contributing Cause and the 120 day rule in Sanchez v. Yellow Transport, 1D19-4231.

The crux of the case was the E/C had authorized treatment over the years for the “lumbar spine”, and had never delineated that they were accepting a lumbar strain or any specific diagnosis.   When the doctor made a referral to pain management for the diagnosis of lumbar degenerative disc disease and spondylosis with stenosis, the E/C denied further care as the accident did not remain the major contributing cause of the need for treatment.  However, the words used for authorization (for well beyond 120 days) were simply “lumbar spine”

The 1st DCA stated:

Under this case law, the key to the MCC issue here is the identity of the accepted compensable injury. According to Claimant, the E/C accepted compensability of his low back injury,
without qualification and inclusive of the lumbar spine.  Significantly, the JCC specifically found that Claimant injured his lumbar spine in the compensable April 21, 2004, accident and that
the E/C authorized Dr. Cohen to treat the lumbar spine. Although the E/C argued that the accepted injury was only a lumbar strain (a “minor” injury), they concede, as the JCC expressly noted, there is no medical evidence of a lumbar strain. In fact, there is no supporting evidence of a specific accepted diagnosis whatsoever.

The lesson is to be specific in what you authorize, and if needed, clarify what the accepted diagnosis is within 120 days of the initial treatment.

So, in a perfect world, what should happen is:

  • Claimant reports a low back injury
  • Adjuster authorizes “non-degenerative/non-preexisting lumbar spine” treatment at the walk-in clinic level.  Perhaps authorize “only the injuries that the major contributing cause is the accident of _____”
  • After getting an actual diagnosis, perhaps after an ortho visit, but within 120, re-confirm authorization to the doctor of the specific accepted injury. (authorized to treat the lumbar strain or aggravation of L4-5 DDD)
  • Adjuster issues dwc-12 denial of all other conditions of the  lumbar spine other than the specific accepted injury.

Perfect worlds are hard to come by (especially in 2020, but I digress).   At a minimum, we need to tighten up our language at the onset of the claim in the initial authorization to avoid 120 day issues.

Our firm is putting together a CEU on this topic, MCC and the 120 day rule, along with the 3/10 day rule.   It should be ready in a few weeks, hopefully for a webinar in November.  The Sanchez case is attached.