What the panel treated as outcome-determinative, and which side it favoured.
Defendant failed to prove a material change in applicant's condition to justify termination of home health care.
Favours Applicant prevailed
This failure led to affirmance of ongoing treatment obligation.
From the decision · page 11In summary, we agree with the WCJ that defendant has not met its affirmative burden of
establishing a material change in applicant's medical treatment or circumstance that would
otherwise require defendant to either authorize the requested treatment or submit the request to
UR. Because there was no valid medical dispute arising out of a change in condition or
circumstance, we concur with the WCJ's determination that defendant is obligated to continue to
provide treatment in the form of home health care services, unless and until defendant
demonstrates a material change in applicant's condition or circumstance.
Applicant sustained traumatic brain injury with multiple skull fractures and required decompressive craniectomy surgery.
Favours Applicant prevailed
This established the serious nature of the industrial injury requiring ongoing care.
Treating physician Dr. Yong Lee consistently recommended ongoing home health care throughout 2019.
Favours Applicant prevailed
Supported the finding of ongoing medical necessity for home health care.
From the decision · page 10However, the WCJ also correctly notes that as applicant's treating physician, Dr. Lee
continued to update his treatment notes throughout 2019 and identified a consistent array of some
22 medical diagnoses. Dr. Lee recommended continuing provision of multi-modality therapeutic
rehabilitation in conjunction with home health aide services throughout 2019. (Report, at p. 4.)
The RFAs authored by Dr. Lee on May 23, 2019, August 15, 2019, and September 12, 2019 all
review applicant's subjective and objective indicia of progress, and nonetheless reiterate the
physician's recommendation for continued, ongoing home health care as part of applicant's
comprehensive rehabilitation program. In addition, the May 23, 2019 and August 15, 2019 RFAs
Defendant's UR determinations on May 30, 2019 and August 22, 2019 certified the medical necessity of home health care services.
Favours Applicant prevailed
Provided objective confirmation of ongoing medical necessity.
From the decision · page 8September 27, 2018, at p. 1; Petition, at p. 3:2.) The home health services were subsequently
determined to be medically necessary by defendant's UR provider on May 30, 2019. (Ex. H, UR
Notice of Determination, dated May 30, 2019, at p. 1.) Therein, the physician reviewer noted that
the submitted medical record sufficiently documented applicant's subjective complaints, and that
applicant had been reevaluated by neurologist Dr. Wogensen, who concurred with Dr. Lee in the
need for ongoing treatment through the TLC and ongoing home health care. The reviewer noted
the medical necessity of the request for home health aide services was necessary to "overcome
deficits in activities of daily living...." (Id. at p. 7.)