What Does “Reasonable and Necessary” Medical Treatment Mean in an Alabama Workers Compensation Claim?

What Does “Reasonable and Necessary” Medical Treatment Mean in an Alabama Workers Compensation Claim?

If you have been injured at work in Alabama, you have probably heard someone mention that workers’ compensation only has to pay for medical treatment that is “reasonable and necessary,” but what does it actually mean?

More importantly, who decides whether medical treatment is “reasonable and necessary”?

The General Rule

Under Alabama’s Workers’ Compensation Act, employers are generally required to pay for Reasonably necessary medical and surgical treatment related to a compensable work injury (see Ala.Code 25-5-77(a)).

This means that workers’ compensation does not automatically pay for every treatment recommended by the authorized treating physician must be both:

1. Related to the work injury; and
2. Reasonable and necessary to diagnose, treat, or improve the condition.

What Types of Treatment Are Considered Reasonable?

Reasonable medical treatment basically refers to care that is both medically necessary and delivered in a way that is clinically appropriate, safe, and aligned with accepted medical practice for the patient’s condition.  If the Authorized Treating Physician believes the treatment is medically appropriate and related to the injury, that is often strong evidence that the treatment is reasonable and necessary.

Who Decides What Treatment Is Necessary?

In most Alabama workers’ compensation cases, the Authorized Treating Physician plays the most important role.

The Authorized Treating Physician is the doctor selected through the workers’ compensation system to direct your medical care and generally speaking, the physician’s recommendations carry significant weight.  If the workers compensation insurance carrier disputes whether suggested medical care is reasonably necessary, then they may ask for an independent medical evaluation (IME) or have a utilization review performed to see if this doctor disagrees with the authorized treating physician.  If this occurs, you should contact an experienced Alabama workers’ comp lawyer for assistance as the medical care the treating physician states is needed is being denied.

Why Do Treatment Disputes Occur?

Despite the physician’s recommendations, disputes sometimes arise. The workers’ compensation insurance carrier may question:

• whether the treatment is related to the work injury
• whether the treatment is likely to:
  • improve the condition,
  • prevent further deterioration of the workers’ condition,
  • relieve the injured worker from the effect of their condition by restoring them to a basic level of bodily functioning or appearance (see Ex parte Mitchell, 989 So.2d 1083, 1092 (Ala.2008).

• whether less expensive treatment alternatives exist
• whether additional treatment is medically necessary

These disputes are not uncommon when surgery is recommended, long-term pain management is requested, expensive diagnostic testing is ordered, treatment continues for an extended period of time or where the injured worker is not represented by counsel.

Does “Reasonable and Necessary” Mean Treatment Must Cure Me?

No, and this is a common misunderstanding.  Medical treatment does not have to completely cure an injury to be considered reasonable and necessary.  Treatment may still qualify if it: reduces pain, improves function of a body part or the body as a whole, prevents worsening of the condition, assists in recovery or helps maintain an injured worker’s current level of functioning.

Many work injuries cannot be completely cured but that does not mean treatment is no longer necessary.

Can the Insurance Carrier Override My Doctor?

Not automatically. While disputes sometimes arise, workers’ compensation carriers generally cannot practice medicine or simply substitute their own opinions for those of the treating physician; however, carriers may seek:

• utilization review
• independent medical examinations (IMEs)
• legal review by their attorneys or the Court

when they believe treatment is not reasonable or necessary.

What Happens If Treatment Is Denied?

If recommended treatment is denied, several questions become important:

• Was the treatment properly recommended?
• Is the treatment related to the work injury?
• Was the denial based upon medical evidence?
• Has the employer failed to provide necessary care?

In some circumstances, disputes regarding medical treatment require legal intervention.

The phrase “reasonable and necessary medical treatment” is one of the most important concepts in Alabama workers’ compensation law. It represents the balance between ensuring injured workers receive the care they need while preventing unnecessary medical treatment unrelated to the work injury. In most cases, the opinions of the Authorized Treating Physician play a significant role in determining what treatment is reasonable and necessary, but disputes do occasionally occur.

Understanding this concept can help injured workers better understand both their rights and the challenges that sometimes arise during the workers’ compensation process.

If your workers’ compensation carrier has denied treatment, delayed approval of recommended care, or disputed whether treatment is reasonable and necessary, it may be helpful to speak with an attorney experienced in Alabama workers’ compensation law. At Powell and Denny, we have spent decades helping injured workers obtain the medical treatment and benefits they are entitled to receive under Alabama law.

If you have suffered a job injury and you have questions about your rights and benefits under Alabama’s workers compensation laws -don’t hesitate to contact and speak with one of the experienced Alabama Workers Compensation and Social Security Disability attorneys at Powell and Denny today for a free consultation. Appointments are available in person, or virtually via Zoom if more convenient.  Powell and Denny would appreciate the opportunity to help.  And remember, there is no fee unless you win.

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