Making Coverage Decisions in Washington Workers’ Compensation Claims
Murray v. State of Washington, Dep’t of Labor & Indus. (Dec. 6, 2018)
Washington Supreme Court
This ruling by the Washington Supreme Court complicates the relationship between the Health Technology Assessment program (“HTA”)’s Health Technology Clinical Committee (“HTCC”)’s coverage determinations for workers’ compensation claims moving forward. Prior to this decision the HTCC acted as an independent committee of practicing medical professionals that would evaluate procedures and technology. The HTCC uses medical and scientific evidence about new medical technologies and procedures to determine if the State of Washington would cover these procedures when they are sought by parties seeking treatment in the Department of Social and Health Services, Washington’s Healthcare Authority and the Department of Labor & Industries systems.
The draft HTA allowed for an appeal of decisions by the HTCC, but this section was vetoed by Governor Gregorie when the HTA was passed in 2006. The Governor’s comment at the time was that there were appeals available under existing laws to challenge these coverage decisions.
In 2010, the HTCC started evaluating a treatment known as femoroacetabular impingement syndrome hip surgery (“FAI”). After a year of review and research the HTCC determined the evidence weighed against FAI and the treatment would not be covered and the participating state agencies were required to comply with this HTCC decision.
The Claimant, Michael Murray, injured his hip in 2009. His doctor recommended FAI for treatment and the Department of L&I denied coverage based upon the HTCC decision on FAI. Murray’s doctor performed the surgery without authorization and successfully rehabilitated Murray’s injury. Murray appealed and was denied at the Board, Superior Court and the Court of Appeals on similar grounds that the FAI was not approved under the HTCC’s decision.
The Supreme Court reviewed the interplay between HTC and the workers’ compensation laws. They determined that the HTCC’s decisions were advisory and given greater weight than medical advisory committee under WAC 296-20-01001, but ultimately they do not have conclusive effect and the Department must make the decision if a treatment is covered. This decision would then be appealable to the Board and Superior Court. Therefore Murray should have had the opportunity to rebut the presumption created by the HTCC determination and the case was remanded for these proceedings.
This decision takes away the certainty of the HTCC decisions at the Department level and beyond. It makes the facts of each individual case subject to a necessary and proper determination by the Department that then is appealable to the Board and beyond under RCW 51.52. This will create another layer of appealable decisions that will complicate the resolution of workers compensation claims involving controversial or emerging technologies and treatments. Please contact us if you have any question on how this decision applies to your claim processing.