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Should long-term opioid painkillers be covered under workers’ comp?

An employee injured his back 13 years ago. A pain medicine specialist says opiate medications reduce his pain, improve his quality of life and overall function. His former employer’s insurance company doesn’t want to continue to pay because he’s reached maximum medical improvement. How did a court rule? 

On May 18, 2006, Terry Hagberg injured his back while lifting a 200-250 pound unit while working for NAES Power in Rosebud County, MT. Hagberg injured his back in a forceful, twisting movement in a flexed position. Movement like that puts the lumbar spine at a greater risk for injury.

Hagberg had segmental decompression surgery in September 2006. In January 2007, a doctor said Hagberg had reached maximum medical improvement (MMI) with a 26% whole person impairment. Hagberg would rate his pain between 8-10 on a 10-point scale during medical check-ups, and was referred to a pain management doctor. The doctor prescribed opiate medications for his back pain.

In July 2016, Hagberg underwent an Independent Medical Examination (IME) by a general orthopedic surgeon who specializes in the low back and spine.

The IME doctor said Hagberg’s pain was due to a degenerative condition, not his work injury, and that the opiate prescription wasn’t related to the work injury either.

Based on the doctor’s opinion, the insurance company denied liability for further medical benefits. The pain management doctor who had been treating Hagberg wrote a letter in which he disagreed with the IME doctor. The case went before the Montana Workers’ Compensation Court.

Doctor vs. doctor

Which doctor’s opinion carried more weight: the pain management doctor who had been treating Hagberg for 12 years or the IME doctor?

The doctors had equal credentials and experience. The court found Hagberg’s pain management doctor based his opinions on better evidence than the IME doctor. The pain management doctor incorporated the mechanism and severity of Hagberg’s injury into his findings that his current pain results from his 2006 injury.

Also, as a general rule, the opinion of the treating doctor is given greater weight than that of a competing expert.

For those reasons the court agreed with the pain management doctor.

The second question for the court: Are Hagberg’s prescription pain medications primary medical services that are covered under workers’ comp, or palliative or maintenance care that aren’t covered?

Montana’s workers’ comp law defines primary medical services as “treatment prescribed by a treating physician, for conditions resulting from the injury, necessary for achieving medical stability.”

The state’s supreme court had said in a previous ruling that achieving medical stability also means the sustaining  medical stability. The workers’ comp court found Hagberg’s prescription pain medications are necessary to sustain him at MMI.

For that reason, the Montana Worker’s Compensation Court ruled Hagberg’s pain medications should be covered under workers’ comp.

(Terry L. Hagberg v. Ace American Insurance Co.Workers’ Compensation Court of Montana, WCC No. 2018-4206, 4/15/19)

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