A Stronger Defense Against Motions for Medical Treatment: Why a Doctor’s Report may no Longer be Sufficient to Support a Petitioner’s Request for Treatment

By Daniel A. Abelson, Esq.

The Appellate Division recently released its decision in the case of Amedeo v. UPS, No. A-1013-13T2 N.J. Super. Unpub. LEXIS 753 (App. Div. April 8, 2015). In Amedeo, the court reshaped the evidentiary standard for a petitioner to prevail on a Motion for Medical Treatment and/or Temporary Disability Benefits (hereinafter called a “Motion for Medical Treatment”). The Court’s decision will likely have a great impact on the way practitioners file motions and the way respondents defend them.

In Amedeo, the petitioner was originally involved in a work accident wherein he sustained injury to his hip. The original case settled, and in October 2012, petitioner reopened his claim alleging a worsening of his hip pain, and requesting additional medical treatment for same. Petitioner obtained a report from an internist and psychiatrist, Dr. Brustein, to determine the need for orthopedic hip surgery. The doctor recommended additional treatment, including an evaluation with a university affiliated orthopedist specializing in hips, a spinal specialist, and a pain management specialist. Petitioner then filed a Motion for Medical Treatment, and included Dr. Brustein’s report in support of his Motion.

In a written statement, the judge of compensation found petitioner’s Motion was deficient under N.J.A.C. 12:235-3.2(b)(2). Amedeo, at 4. The judge reasoned Dr. Brustein was not an orthopedic surgeon but practiced internal medicine and physiatry, and “had no intention to treat the petitioner” because any proposed treatment to the injured areas would be outside of “his area of expertise.” Id. Rather, the judge found that Dr. Brustein’s report merely suggested that petitioner seek out other specialists such as a “university affiliated orthopedist” specializing in hips, a spinal orthopedist, and a pain management specialist. Id. at 5. The Judge of Compensation further found N.J.A.C. 12:235-3.2(b)(2) that was designed to eliminate non-specific reports, such as Dr. Brustein’s, by requiring applicants to obtain precise and detailed opinions by appropriate experts. Id.

Petitioner appealed the Judge’s decision to the Appellate Division, who ultimately agreed with the Judge of Compensation in their unanimous decision. Id. at 7. The Court reasoned Dr. Brustein’s suggestions were not sufficient to satisfy N.J.A.C. 12:235-3.2(b)(2), which requires specificity in order for the compensation judge to evaluate and appraise the validity of such motions. Id at 8. Therefore, the Appellate Court upheld dismissal of petitioner’s Motion without prejudice. Id. at 7.

The decision in Amedeo requires stricter interpretation of the existing rule stated in N.J.A.C. 12:235-3.2(b)(2). N.J.A.C. 12:235-3.2(b)(2) states in part “The notice of motion for temporary disability or medical benefits shall…contain the report of a physician stating the medical diagnoses and the specific type of diagnostic study, referral to specialist, or treatment being sought.” The holding in Amedeo adds to this standard by interpreting N.J.A.C. 12:235-3.2(b)(2) to eliminate non-specific medical reports, such as those that merely suggest several options for other specialists to try. Id. at 5 and 8. Thus, in order for a petitioner to show with sufficient proof he requires additional treatment causally related to his work accident, the petitioner must obtain precise and detailed opinions by appropriate experts.

Before Amedeo, a report from a doctor with a medical diagnosis and treatment recommendation, even if only recommending treatment by other doctors-to-be named, was sufficient to support a prima facie need for treatment under N.J.A.C. 12:235-3.2(b)(2). All too often, the petitioner would obtain a doctor’s report from one of their regular permanency evaluators, an internist, or a pain management specialist, who recommends the petitioner be evaluated by an orthopedist to determine whether surgery is necessary. Under such circumstances, the respondent was compelled to schedule its own need for treatment evaluation, often times with an expensive specialist who is an expert in the medical field where treatment is being sought. In effect, the respondent was being compelled to do petitioner’s homework by seeking out the appropriate doctor to evaluate the petitioner.

That is no longer the case after Amedeo. Respondents can now successfully argue a recommendation from petitioner’s doctor to see a specialist to determine the appropriate medical treatment is insufficient evidence to support a need for causally related treatment, prima facie or otherwise. Thus, the respondent may be able to avoid scheduling its own treatment evaluation. In effect, Amedeo cuts out the doctor who essentially acts as a “middle man,” and increases the burden on petitioner, encouraging him to use treating doctors who are experts in providing the treatment he is requesting from the outset.

Context is important. For example, suppose a petitioner requests lumbar spine surgery. The petitioner sees an orthopedist who does not recommend surgery, but does recommend pain management treatment in the form of an epidural steroid injection to be performed by a pain management specialist. In this scenario, it was reasonable for the petitioner to see the orthopedist at the outset, as he was requesting lumbar spine surgery. Further, as the orthopedist evaluated petitioner and did not recommend surgery, it was reasonable for him to recommend he see a pain management specialist to determine alternative treatment options. Thus, this will likely not conflict with the new Amedeo standard.

However, what if the doctor who evaluates petitioner has limited experience in that specialty? For example, suppose petitioner requests orthopedic surgery for his alleged work injuries, and is evaluated by an internist. Is the internist’s opinion regarding the need for orthopedic surgery still good under the Amedeo standard? Probably not.

In light of the Amedeo decision, respondents should carefully review which doctor petitioner is using to support his request for treatment. Raising the defense that petitioner’s doctor is not recommending any actual treatment, or is not qualified to make the appropriate treatment recommendation being sought, carries a greater weight under the heightened standard in Amedeo. This is a great case for respondents.