In Toyota Motor Manufacturing v. Lawson, No. 2008-002386-WC and 2009-CA-00064-WC (Kentucky Court of Appeals 2009).  the Court of Appeals addressed a claim arising from claimant’s motion to reopen alleging her entitlement to temporary total disability and permanent disability benefits based upon the worsening of her condition, and Toyota’ s failure to formally contest a proposed surgery by filing a medical fee dispute. The ALJ found Toyota was not required to file a medical fee dispute to contest the proposed surgery and then found the surgery not to be reasonable or necessary.  The Workers’ Compensation Board reversed, saying Toyota was required to file a formal fee dispute via a motion to reopen within 30 days of the utilization review.

The Court of Appeals disagreed, holding Toyota was under no obligation to contest the proposed surgery because there had been no services rendered and there was no bill to contest. The Court reasoned that the legislature did not incorporate the subject of preauthorization for medical treatment into the language of KRS 342.020, which sets forth the 30 day time period for contesting a statement for services.

Comment: While the Court’s holding seems simple enough, it may have been too simple.  The Court interpreted KRS 342.020 based on precedent dealing with medical contests involving the rendering and billing of services.  This line of cases came before enactment of Utilization Review (UR) procedures.  Once UR procedures were enacted under 803 KAR 25: 190, employers were required to conduct UR in certain situations where preauthorization was requested – the very situation present in Lawson. The Lawson court’s holding would seem to render that particular regulation toothless.

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