We often see a doctor recommend treatment/testing to “rule in or rule out” that the injury is the cause of the ongoing symptoms or complaints. Common examples are blood work to see if there is any possible disease, a cervical MRI on a wrist/shoulder injury, bilateral EMG’s for comparison, etc….The doctor is in essence trying to determine the actual cause of the problem.
If the purpose of the testing is to determine the cause of the need for treatment, the claimant does NOT have to prove major contributing cause under a “rule in/rule out” scenario:
Chance v. Polk Co. School Bd., 1DO8-2235 (Fla. 1st DCA 2009).
- The JCC applied the incorrect standard when he held the claimant was not entitled to a diagnostic MRI. The claimant had to establish a causal relationship between her injury and the compensable accident in order to secure treatment, but not to be entitled to diagnostic testing to determine the cause of symptoms. The claimant’s doctor testified an MRI was necessary to determine the exact cause of the claimant’s right shoulder pain. Therefore, the test was compensable, even if the claimant’s right shoulder condition was eventually determined to be non-compensable.
- “A claimant must establish a causal relationship between his injury and the compensable accident in order to secure treatment, but not to be entitled to diagnostic testing to determine the cause of his symptoms.” Grainger, 869 So. 2d at 1271
A word of caution, if you start treating or authorizing testing on an unrelated or unauthorized body part, you should still issue a denial afterwards to avoid any argument you accepted that condition under the 120 day rule. In fact, to be safest, also include when you do authorize it, that the testing is authorized only for rule in/rule out purposes, the body part in question is not compensable.
I am always available to help you strategize.
Morgan Indek | Managing Partner