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All Contested Case Subject
Medical Issues
In General
In a medical fee dispute, the director's order finding the insurer not liable for various charges related to a drug screen protocol administered to the worker or for a rebilling fee was affirmed. Becker, Tim A.,
15 CCHR 111 (2010).
Dismissal of claimant's request for review of an MCO matter was in error where the division gave claimant's counsel three business days to submit information not required by form 2842, and neither 436-010-0008 nor bulletin 293 provide a 3-day time frame, nor do they mandate dismissal for noncompliance. Brown, Kory L.,
15 CCHR 100 (2010).
WCD not required to include notice of right to request reconsideration or inform parties that requesting hearing may bar admission of new medical evidence in notice of appeal rights on administrative orders. Rice, Jeremy E.,
15 CCHR 89 (2010).
Under OAR 436-010-0250, the insurer was not barred from disputing proposed elective surgery because, under 436-010-0250(2), a doctor's initial seven day notice of proposed elective surgery did not meet the additional requirement, under 436-010-0250(4), that a doctor provide notice that an agreement could not be reached regarding surgery. Walker, Michael,
15 CCHR 48 (2010).
The medical provider was not entitled to charge a special report or rebilling fee of $50 per month because, under 436-009-0030, it was not the equivalent of a reasonable monthly service charge, where the rebilling fee bore no relation to the amount due. Kotsios, Melena K.,
15 CCHR 36 (2010).
The medical provider was not entitled to charge a special report or rebilling fee of $50 per month because, under 436-009-0030, it was not the equivalent of a reasonable monthly service charge, where the rebilling fee bore no relation to the amount due. Kotsios, Melena K.,
15 CCHR 30 (2010).
The director's order of dismissal was supported by substantial evidence, where the record supported the director's findings that medical services were directed toward pre-existing, non-compensable conditions that were denied through litigation. Young, Kristi R.,
15 CCHR 8 (2010).
Under ORS 656.247, the insurer was not liable for interim benefits because the worker's claim was denied, and the worker was not covered by a health benefit plan. Smith, Kevin P.,
14 CCHR 191 (2009).
The Director affirmed both the ALJ's proposed and final order and the RT's order because the massage therapist was not directly supervised, because the physician was not physically present at the time services were provided, and the record lacked any evidence supporting the argument that massage therapists "are pactitioners of a healing art." Burchett, Dennis K.,
14 CCHR 156 (2009).
ORS 656.247 is not ambiguous; when read as a whole it authorizes payment of interim medical benefits when a claim is accepted, or when a claim is denied and the worker has health insurance coverage. Claimant was not entitled to pre-denial medical benefits because he lacked insurance coverage during the relevant period. Smith, Kevin P.*,
14 CCHR 159 (2009).
A "re-billing fee" is not an authorized monthly service charge for untimely payment of medical charges under 436-009-0030(7); and an authorized monthly service charge is unreasonable when in excess of 30 percent of a past due amount. Warren, Debra J.,
14 CCHR 166 (2009).
Claimant's request for reimbursement of lodging expenses denied because claimant failed to show a need to stay in the hotel that was reasonably related to the injury. Larsen, Holly A,
14 CCHR 134 (2009).
The massage therapy services that were provided are not reimbursable because the massage therapist and the attending physician were not practicing under the same office, so the massage therapist was not under the direct control and supervision of the attending physician. Burchett, Dennis K.*,
14 CCHR 111 (2009).
A license as a massage therapist does not grant a license to provide medical services. Burchett, Dennis K.*,
14 CCHR 111 (2009).
Claimant's previous request for director review of insurer's refusal to pay for a prescription medication was premature because at the time that claimant had requested the review, insurer had not yet accepted the claim. Champion, Ranee,
14 CCHR 106 (2009).
The issue of insurer's liability for the surgery is "ripe for review" because the doctor's chart note clearly shows that the doctor had not changed his mind about the appropriateness and necessity of the proposed surgery; rather, the doctor simply feels that surgery should wait for a period of time. Martinez, Antonio,
14 CCHR 61 (2009).
Doctor's $7,200 fee for spending 8 hours writing a response to an IME report is held not reasonable because the response is more elaborate than necessary. Doud, Michael J.,
14 CCHR 40 (2009).
When the issue is whether the insurer is required to pre-authorize the medical treatment proposed by claimant's doctor, and it is not based on a matter concerning a claim under ORS 656.704(3)(b)(C), the dismissal order is within the director's jurisdiction. Jones, Janine D.,
14 CCHR 36 (2009).
RT's approval of the insurer's denial of payment for a records review on the basis that the insurer had not requested the records review ignored OAR provisions that do allow for payment and therefore the matter is remanded. Gilbert, Timothy R.,
14 CCHR 24 (2009).
A medical services dispute is not ripe for WCD adjudication because OAR 436-009-0010 requires that medical providers submit bills on the HCFA form accompanied by chart notes in order to receive payment, and the self-insured employer has not yet received that documentation. Wofford, Shannon,
13 CCHR 505 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Coen, Ruthanne,
13 CCHR 318 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Coen, Ruthanne,
13 CCHR 318 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Loose, Jacob R,
13 CCHR 408 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Loose, Jacob R,
13 CCHR 408 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Harris, Kenneth R,
13 CCHR 368 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Harris, Kenneth R,
13 CCHR 368 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Cox, Jonathan A,
13 CCHR 328 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Cox, Jonathan A,
13 CCHR 328 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Braatz, Richard J,
13 CCHR 308 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Braatz, Richard J,
13 CCHR 308 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Schafer, Raymond E,
13 CCHR 488 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Schafer, Raymond E,
13 CCHR 488 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Perkins, Craig E.,
13 CCHR 478 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Perkins, Craig E.,
13 CCHR 478 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. McCann, Jack D,
13 CCHR 428 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). McCann, Jack D,
13 CCHR 428 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Oneal, Dan R,
13 CCHR 458 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Oneal, Dan R,
13 CCHR 458 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Hartman, Robert N,
13 CCHR 378 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Hartman, Robert N,
13 CCHR 378 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Moss, Deborah l,
13 CCHR 438 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Moss, Deborah l,
13 CCHR 438 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Kelso, Larry W,
13 CCHR 398 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Kelso, Larry W,
13 CCHR 398 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Downing, Brian T,
13 CCHR 348 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Downing, Brian T,
13 CCHR 348 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Nocita, Sebastian J.,
13 CCHR 448 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Nocita, Sebastian J.,
13 CCHR 448 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Davis, James B.,
13 CCHR 338 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Davis, James B.,
13 CCHR 338 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Franke, Shiree,
13 CCHR 358 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Franke, Shiree,
13 CCHR 358 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Aveleigra, Jose A,
13 CCHR 298 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports WCD's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Aveleigra, Jose A,
13 CCHR 298 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Hernandez, Fermin H,
13 CCHR 388 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Hernandez, Fermin H,
13 CCHR 388 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Martsfield, Brian P,
13 CCHR 418 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Martsfield, Brian P,
13 CCHR 418 (2008).
Hospital charges for services provided by radiologic technologists should be paid under the cost/charge ratio, not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS), because radiologic technologists are not "licensed medical service providers" that practice one or more of the healing arts. Penland, Kirk A,
13 CCHR 468 (2008).
The text and context of OAR 436-009-0020(2), including the rule's history and the division's intent when adopting the rule, supports the division's interpretation that radiologic technologists should be paid under the adjusted cost/charge ratio and not under the current procedural terminology (CPT®) codes with their associated resource based relative value units (RBRVS). Penland, Kirk A,
13 CCHR 468 (2008).
Per OAR 436-010-0220(2) claimant's pre-surgery hospital charges for a compensable injury are not compensable because claimant's attending physician did not authorize the surgery. Kraft, Ronald G.,
13 CCHR 289 (2008).
OAR 436-009-0025(3), which requires a request for reimbursement to be submitted within two years, applies only prospectively. Clendenon, Daniel M,
13 CCHR 233 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Franke, Shiree*,
13 CCHR 142 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). McCann, Jack D*,
13 CCHR 184 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Braatz, Richard J*,
13 CCHR 112 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Harris, Kenneth R*,
13 CCHR 148 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Martsfield, Brian P*,
13 CCHR 178 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Kelso, Larry W*,
13 CCHR 166 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Downing, Brian T*,
13 CCHR 136 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). O'Neal, Dan R*,
13 CCHR 202 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Schafer, Raymond E*,
13 CCHR 220 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Davis, James B.*,
13 CCHR 130 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Nocita, Sebastian J.*,
13 CCHR 196 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Cox, Jonathan A. *,
13 CCHR 124 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Coen, Ruthanne*,
13 CCHR 118 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Moss, Deborah L*,
13 CCHR 195 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Perkins, Craig E*,
13 CCHR 214 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Hartman, Robert N*,
13 CCHR 154 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Aveleigra, Jose A.*,
13 CCHR 106 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Penland, Kirk A*,
13 CCHR 208 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Loose, Jacob R*,
13 CCHR 172 (2008).
A radiologic technologist is not a "medical service provider" as that term is defined by ORS 656.260(12) and OAR 436-10-0005(29). Hernandez, Fermin*,
13 CCHR 160 (2008).
Even if two doctors attributed some of claimant's symptoms to a prior compensable injury, one doctor's opinion that the treatment was provided for a more recent non-compensable injury is substantial evidence and therefore supports the finding by the MRU that the treatment was provided for the non-compensable injury. Guzman, Adrian,
13 CCHR 98 (2008).
The director did not err in dismissing claimant's request for administrative review regarding interim medical benefits where no evidence existed that claimant had a health benefit plan and no evidence existed that the director had jurisdiction to consider the matter since the denial was unappealed. Monroe, Jimmy D,
13 CCHR 101 (2008).
ORS 656.245(1)(a) and (b) provide that for every compensable injury, the insurer is compelled to provide medical services for conditions caused in material part by the injury for such period as the nature of the injury or the process of recovery requires. Jimenez, Tammie D,
13 CCHR 81 (2008).
ORS 656.247 requires that a worker have a health benefit plan as a precondition to payment of interim medical services on a denied claim, and it describes no alternative procedure for payment of interim medical services when a claim is denied and no health benefit plan exists. Keller, Tamara,
13 CCHR 85 (2008).
OAR 436-009-0035(7) explicitly stating that if a worker has no health benefit plan, the carrier is not required to pay for interim medical benefits is consistent with ORS 656.247 and does not exceed statutory authority. Keller, Tamara,
13 CCHR 85 (2008).
ORS 656.245(2)(b)(A) clearly provides the legislative intent that by at least 31 days after the date of injury, medical services are not compensable without an attending physician's written authorization, and is not limited to just doctors who are not qualified to be attending physicians. Kraft, Ronald G.*,
13 CCHR 73 (2008).
If silent, rules are applied retroactively when they are remedial or procedural as opposed to substantive in nature. Clendenon, Daniel M*,
13 CCHR 34 (2008).
When the amendment to a rule restricts an injured worker's remedy by placing a time limit on it, the amendment is substantive in nature. Clendenon, Daniel M*,
13 CCHR 34 (2008).
The plain language of ORS 656.247(4)(b) makes a worker's coverage by a health benefit plan a condition precedent to any payment of interim bills by the workers' compensation carrier. Blacknall, Jr., Reese*,
12 CCHR 316 (2007).
When claimant does not have a health benefit plan, the workers' compensation carrier is not required to pay interim medical benefits. Blacknall, Jr., Reese*,
12 CCHR 316 (2007).
When the disputed medical services are not compensable, there is nothing left for MRU to review. Tran, Tin T*,
12 CCHR 118 (2007).
The fact that the treatment was to be directed to the same spinal level as the accepted condition does not itself establish a causal relationship. Hayes, William L,
12 CCHR 112 (2007).
All nurse practitioners, even those under supervision of an attending physician must become authorized by the director prior to providing any compensable medical services under ORS 656.245 to injured workers. Rojo-Heredia, Hector,
12 CCHR 84 (2007).
Before determining if curative care is compensable, the issue of authorization must be addressed, which requires factual findings and legal conclusions. Kraft, Ronald,
12 CCHR 58 (2007).
To establish the date for timeliness of a request for review, MRU will consider the date postmarked, the date automatically produced by transmitting a fax, or the date a hand-delivered document is date-stamped by WCD. Wynkoop, John,
12 CCHR 37 (2007).
When a worker's family member provides home health care, for reimbursement there must be evidence that the family member demonstrated home health care competency to the satisfaction of the attending physician. Sullins, Jeffrey A,
12 CCHR 25 (2007).
Attending physicians my prescribe treatment by a person not licensed to provide medical services only when the treatment is rendered under the direct control and supervision of the attending physician. Sullins, Jeffrey A,
12 CCHR 25 (2007).
Under OAR 436-010-0210 home health care may be provided by a worker's family member without the direct control and supervision of the attending physician, if the attending physician prescribes such care and the family member demonstrates competency to the satisfaction of the attending physician. Hanke, Coriena R,
12 CCHR 22 (2007).
Housekeeping and grocery shopping services are not considered medical services and are not intended by ORS 656.245 to be reimbursed. Hanke, Coriena R,
12 CCHR 22 (2007).
To qualify as an authorized nurse practitioner, a nurse practitioner must certify in a form provided by the director that the nurse practitioner reviewed a packet of materials. Rojo-Heredia, Hector*,
11 CCHR 294 (2006).
Podiatrists can only provide compensable medical services for 30 days from the date of injury without a referral from an attending physician. Gotthardt, Deborah L,
11 CCHR 262 (2006).
When a claim is in denied status and there is no order from an authorized attending physician, claimant is not exempt from application of workers' compensation laws. Gotthardt, Deborah L,
11 CCHR 262 (2006).
In OAR 436-010-0230(12), the term "in use" is restrictive and inconsistent with the statutory definition of a compensable injury under ORS 656.005. The rule is invalid because it does not allow compensation for damage to a prosthetic appliance that would otherwise be compensable. Toussaint, Gloria,
11 CCHR 107 (2006).
When a claim is open and the statutory and administrative requirements are met, the medical services available to claimant are not limited to the exceptions listed in ORS 656.245. Seaman, William D,
11 CCHR 65 (2006).
The insurer is liable for the full amount of worker requested medical examination fees except for travel and research. Boydston, Randy D*,
11 CCHR 13 (2006).
A service that provides billing for a pharmacy and does not provide pharmaceuticals or medical services is not a medical service provider or an agent for billing purposes. Vendehay, Tim J.,
10 CCHR 247 (2005).
Insurer may use a pharmacy billing service that does not limit a claimant's right to choose a pharmacy. Vendehay, Tim J.,
10 CCHR 247 (2005).
An insurer is not required to pay a pharmacy that does not submit invoices using an NCPDP form. Vendehay, Tim J.,
10 CCHR 247 (2005).
Insurer is not required to pay a pharmacy that does not bill at the lower of either the provider's customary rate or the Oregon fee schedule. Vendehay, Tim J.,
10 CCHR 247 (2005).
A service that provides billing for a pharmacy and does not provide pharmaceuticals or medical services is not a medical service provider or an agent for billing purposes. Ping, Kathryn A.,
10 CCHR 242 (2005).
Insurer may use a pharmacy billing service that does not limit a claimant's right to choose a pharmacy. Ping, Kathryn A.,
10 CCHR 242 (2005).
An insurer is not required to pay a pharmacy that does not submit invoices using an NCPDP form. Ping, Kathryn A.,
10 CCHR 242 (2005).
Insurer is not required to pay a pharmacy that does not bill at the lower of either the providers customary rate or the Oregon fee schedule. Ping, Kathryn A.,
10 CCHR 242 (2005).
Claimant who was provided notice of the 90-day appeal period was time-barred from making a medical claim though he alleged no knowledge of a need for an appeal. Lewis, Darrell G.,
10 CCHR 25 (2005).
Services of a chiropractor are not compensable after the chiropractor ceased to qualify as an attending physician; equitable estoppel did not apply on these facts. Monforton, Stephen P.,
8 CCHR 343 (2003).
Medical services are not related to claimant's compensable condition; physician's change of opinion to the contrary is not persuasive. Gilbert, Lisa E.,
8 CCHR 338 (2003).
MRU's finding that the proposed diagnostic test was not directed to an accepted condition is not supported by substantial evidence. Bottoms, William H.*,
8 CCHR 287 (2003).
Insurer is equitably estopped from denying payment for chiropractic services that were provided after the chiropractor ceased to qualify as attending physician. Monforton, Stephen P.*,
8 CCHR 234 (2003).
The director upheld the ALJ's order finding cryotherapy is not reimbursable because exceptions did not raise new issues. Olsen, Cristine O.,
8 CCHR 232 (2003).
Insurer is not precluded from denying payment for home health care because claimant did not change his position in reliance on any representation. Burland, Theodore F.,
8 CCHR 186 (2003).
Insurer provided adequate notice to limit claimant's mileage reimbursement for visits to claimant's attending physician. Davidson, Brian K.,
8 CCHR 191 (2003).
Cryotherapy is reimbursable only if it is provided in conjunction with primary services performed by a provider who is in direct contact with the patient; the primary services must be directed to compensable condition and reimbursable. Olsen, Cristine O.*,
8 CCHR 123 (2003).
Companion care provided by claimant's wife is not compensable under rules in effect at the time care was provided because claimant's wife was not a licensed care provider and the care not provided under the direct control and supervision of an attending physician. White, Richard L.,
8 CCHR 77 (2003).
MRU correctly found no medical evidence to support the allegation that the chiropractor, whose attending physician status had expired, found claimant to be medically stationary. Hernandez, Abraham T.,
8 CCHR 63 (2003).
Palliative swim therapy is within the definition of 'physical restorative services' and is not compensable because it is not directed to hemiplegia, spinal cord injury, or severe head trauma. Graham, Willie*,
8 CCHR 1 (2003).
Insurer did not improperly terminate the non-MCO physician after claimant became medically stationary, and proper notice was provided. Curtis, Michelle*,
7 CCHR 52 (2002).
No pre-authorization was required by the insurer for the attending physician to refer the claimant to a different physician for a provocative lumbar discography. Rodriguez, Cirilo,
7 CCHR 25 (2002).
Substantial evidence supported MRU's conclusion that claimant's narcotic use in violation of a pain management program was reasonable. McDowell, Durwood,
7 CCHR 16 (2002).
The proposed anterior interbody fusion of L4-5 surgery was found to be reasonable and necessary treatment for claimant's accepted condition. Grout, Ronnie A.,
7 CCHR 5 (2002).
Appropriateness
Director's decision that elective surgery was appropriate is supported by substantial evidence. Williams, Gayle J.,
15 CCHR 147 (2010).
The director's order finding that artificial disc replacement is not appropriate or compensable is supported by substantial evidence. Hanson, Daniel N.,
15 CCHR 95 (2010).
WCD's order finding insurer liable to pay for ambulance transport to the hospital supported by substantial evidence. Hollingsworth, Kaelynn,
14 CCHR 143 (2009).
Substantial evidence supports WCD's finding that the proposed surgery is appropriate because the record, when viewed as a whole while keeping in mind the doctor's evidence against its appropriateness of the back surgery, as well as the other doctors' evidence supporting its appropriateness, permits a reasonable person to make the finding that the proposed surgery is appropriate. Booth, Paul E.,
14 CCHR 100 (2009).
Substantial evidence supports MRU's conclusion that Botox injections were appropriate treatment for claimant's headaches after MRU considered three doctors' opinions, the absence of FDA approval, the absence of the American Academy of Neurology's recommendation, the claimant's history with the treatment, and efficacy studies of the treatment. Powers, Amber,
14 CCHR 26 (2009).
A finding by WCD that a proposed fusion procedure was not appropriate was reasonable and therefore supported by substantial evidence when the finding was based on two neurosurgeons' opinions and little evidence existed in the record to supported the appropriateness of the proposed fusion procedure. Wassgren, Victor J,
13 CCHR 103 (2008).
Based on the record as a whole, a reasonable person would not find that the proposed surgery was appropriate without first dealing with claimant's psychological and substance abuse issues. Harsha, Greg A,
12 CCHR 281 (2007).
The insurer unsuccessfully attempted to use video tape of the claimant engaged in strenuous activity to assert that the proposed surgery was not appropriate. Cervantes, Victor J.,
10 CCHR 378 (2005).
A wheelchair accessible van is reimbursable because the claimant must remain seated during ingress and egress. Jones, Michael G.,
10 CCHR 238 (2005).
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