Benefits: Medical Benefits: Surgery

Gamble v. Sears [01/30/06] 2006 MTWCC 5 Where Respondent did not contend that surgery was not medically necessary, nor that Petitioner’s surgeon was not an appropriate doctor to perform the surgery, and where Respondent’s IME doctor found the surgery to be “very reasonable” and Petitioner’s surgeon did not opine until after the surgery that Petitioner’s injury stemmed from her industrial accident, Petitioner’s failure to receive pre-authorization for the surgery does not absolve Respondent from liability for the medical expenses Petitioner incurred as a result of her condition.
Munroe v. MT Electric & Telephone Pool [8/16/01] 2001 MTWCC 43 Claimant is not entitled to medical benefits for surgery for conditions which are unrelated to her industrial accident.
Beyl v. Liberty Northwest Ins. Corp. [12/21/00] 2000 MTWCC 75 Where persuasive medical evidence demonstrates that claimant's condition will be improved by surgery, the insurer must pay for the surgery.
Harned v. State Fund [6/8/99] 1999 MTWCC 38 Claimant suffered a right-sided disk herniation as the result of a compensable work injury. Following a microscopic laminotomy and disk excision, he continued to complain of low-back and right leg pain. A neurosurgeon recommended additional surgery. Other physicians recommended against surgery. Having reviewed the evidence pretrial, the Court noted during trial that it would order surgery on the condition the physician recommending surgery review the opinions of doctors recommending against surgery and continue his recommendation for surgery. Evidence of the surgeon's review was submitted to the Court. Surgery was ordered as a primary medical benefit to which claimant was entitled. Factors considered by the Court included: the doctor recommending surgery made the most recent examinations and evaluations of claimant, including examination following an incident claimant alleged exacerbated his pain; the persuasive evidence indicated that while the surgery may not cure claimant from all pain, it may alleviate some of his pain; where claimant has not worked since his accident, even a 50% prospect of success may be reasonable if success will increase his functioning and return him to work, whereas that prospect may not be reasonable if he were employed and reasonably functioning; claimant saw the surgeon recommending surgery as part of an independent medical examination.
Alocco v. CIGNA Insurance [6/2/99] 1999 MTWCC 37 On the standard of more probably than not, i.e. 51%, the Court is persuaded that claimant's 1997 herniated disk was caused by a compensable 1995 industrial injury, making the insurer liable for medical treatment and surgery relating to the hernation. Factors considered by the Court included claimant's credible testimony that his pain following the 1995 injury continued, notes in a medical record that he tried to "baby" his pain following the initial incident, and chiropractic records suggesting a continuing condition. On the more likely than not standard, the Court found a rototilling incident emphasized by the insurer was not a new injury, as claimant's radicular symptoms had already been present, and that the exacerbated symptoms following rototilling represented a progression and worsening of existing symptoms, leaving the insurer liable for subsequent medical treatment.
Parham v. State Fund [3/17/99] 1999 MTWCC 24 While there was conflicting evidence on the need for a second surgery to claimant's spine, the WCC credited Dr. Mosely's explanation of the need for surgery, including that claimant's spine is now vulnerable to more serious injury. The insurer is liable for the second surgery as a reasonable primary medical service within sections 39-71-116(26) and -704(1)(a), MCA (1997).
(Evans) Brian v. State Fund [11/22/96] 1996 MTWCC 73 Back surgery was compensable, and penalty and attorneys fees ordered against insurer, where overwhelming evidence indicated claimant's slip and fall caused increased, totally disabling back pain. Insurer's reliance on fact that pre- and post-accident MRIs were the same, and fact that surgery had been recommended prior to the accident, was not reasonable where claimant and physicians made clear her pain increased and total disability ensured and she had previously been working.
Rooney v. Credit General Ins. [06/29/95] 1995 MTWCC 53 Though not all physicians who have evaluated claimant recommend surgery at present, the weight of the evidence indicates surgery is a reasonable medical treatment, making the insurer liable if claimant chooses to undergo surgery. Since surgery may alleviate or diminish some of claimant’s symptoms, he has not reached maximum medical healing, and is entitled to temporary total disability benefits retroactive to the date of their termination.
Beckers v. State Compensation Ins. Fund [02/08/95] 1995 MTWCC 11 Where medical evidence linked claimant’s ongoing need for treatment for his neck condition to industrial injuries, insurer’s reference to subsequent temporary aggravations of claimant’s condition did not sever its liability. Indeed, insurer’s denial of liability in absence of medical opinion that later incidents constituted permanent aggravation was unreasonable, justifying imposition of penalty and attorneys fees.
Pulliam v. Liberty Mutual Ins. Co. [12/29/94] 1994 MTWCC 117 Where claimant’s 1990 fall and resulting disc herniation resulted from her leg giving way, which was a condition caused by her 1988 industrial accident, and her physician opined that her industrial injury weakened her back making her susceptible to later injury, the insurer is liable for 1991 and 1993 surgeries caused by the aggravation.