Amunrud v. Advance United Expressway

STEVEN G. AMUNRUD, Employee/Appellant, v. ADVANCE UNITED EXPRESSWAY and MIGA/ASU RISK MGMT. SERVS., LTD., Employer-Insurer.

MEDICAL TREATMENT & EXPENSE - TREATMENT PARAMETERS; RULES CONSTRUED - Minn. R. 5221.6050. Where the employer and insurer=s notice to the employee=s physical therapist cited specific treatment parameters and suggested that the provider=s treatments were excessive, the compensation judge=s conclusion that the employer and insurer=s compliance with the notice provisions of Minn. R. 5221.6050 was sufficient was neither legally erroneous nor unsupported by substantial evidence.

MEDICAL TREATMENT & EXPENSE - TREATMENT PARAMETERS; RULES CONSTRUED - Minn. R. 5221.6200, subp. 3.B.(2). Where there was no clear evidence in the medical or physical therapy records that the therapy was effective, and where the employee himself testified that his relief by the therapy was very minimal and of only very brief duration, the compensation judge=s conclusion that the employee=s physical therapy was not sufficiently effective in Amaintaining functional status@ to entitle the employee to treatment beyond an additional twelve visits under Minn. R. 5221.6200, subp. 3.B.(2), was not clearly erroneous and unsupported by substantial evidence.

MEDICAL TREATMENT & EXPENSE - TREATMENT PARAMETERS; RULES CONSTRUED - Minn. R. 5221.6050, subp. 8.A. Where it was not unreasonable in light of all of the evidence of record, the compensation judge=s conclusion that the employee was not subject to Aa documented medical complication@ for purposes of satisfying the departure provision of Minn. R. 5221.6050, subp. 8.A., was not clearly erroneous and unsupported by substantial evidence.

MEDICAL TREATMENT & EXPENSE - TREATMENT PARAMETERS. Where there was little medical support for the position that the physical therapy at issue was materially effective in improving or maintaining the employee=s functional status, and where that therapy was not effective in keeping the employee at work, the compensation judge=s conclusion that the employee=s circumstances did not qualify as a Arare case exception@ to the treatment parameters under the Jacka and Asti cases was not clearly erroneous and unsupported by substantial evidence.

Attorneys: David C. Wulff, Law Office of David C. Wulff, Roseville, MN, for Appellant. Michael D. Miller, McCollum, Crowley, Moschet & Miller, Ltd., Bloomington, MN, for Respondents.

The employee appeals from the compensation judge's denial of the employee=s claims for payment for physical therapy and related mileage expenses. We affirm.

On March 20, 1980, Steven Amunrud, at the age of twenty-nine, sustained a work-related herniation of the L4-5 intervertebral disc in his back while lifting hundred-pound sacks of flour in the course of his work as a driver with Advance United Expressway. Subsequent to the injury, Advance United Expressway [the employer] admitted liability and commenced payment of various workers= compensation benefits. Those benefits included payment for treatment with physical therapist James Olson, beginning apparently with one session in March of 1983 and continuing more substantively in March of 1984, and ultimately four separate surgeries, the last being a fusion from L4 to S1 performed in November of 1984. The physical therapy with Mr. Olson eventually came to include various modes, including manual therapy, massage, therapeutic exercise, and hot packs. Mr. Amunrud [the employee] did not have a good result from his surgeries, and, in the years that followed, he continued to experience significant low back and leg pain and related bowel and bladder problems. Additional treatment eventually included pool therapy, myofacial therapies, injections, and several different medications as well. On March 16, 1987, in a letter to attorney Andrew Kline, the employee=s orthopedic surgeon, Dr. Joseph Bocklage, opined that he did not think that the employee could perform even a part-time sedentary job. The employee has now been determined to have been permanently and totally disabled since 1983.

In the years following his injury, the employee remained in increasing pain, which eventually spread to his mid back in addition to his low back. An MRI scan of the thoracic spine in June of 1991 was read as normal, and Dr. Bocklage could suggest no further treatment. On November 22, 1993, Dr. Bocklage noted in a letter to the insurer that the employee had tried various forms of physical therapy and that the only one that seemed to be very effective was his therapy with James Olson.

On May 1, 2000, the employee underwent a lumbar myelogram with CT scan that was read to reveal a solid fusion from L4 through the sacrum, with some mild scarring in that area, some disc degeneration and bulging at L3-4 and L2-3 above the fusion without neural compression, and some further degeneration of the discs at L1-2 and T12-L1. On September 20, 2000, the employee began treating at the United Pain Center with Dr. Todd Hess, on referral from Dr. Bocklage. In his office notes of December 7, 2000, Dr. Bocklage stated, AI think occasional physical therapy is important for [the employee] and I also think that getting Dr. Hess as the main person for [the employee=s] pain will resolve some of those pain demands and dependency that [the employee] has created.@ On March 1, 2001, Dr. Bocklage ordered another lumbar MRI, Aespecially since the pain seems to be intensifying in the upper part of [the employee=s] back in the mid and upper lumbar area.@ The MRI was conducted on March 5, 2001, and was read to reveal the following: (1) solid fusions at L4-5 and L5-S1, without complications or evidence of residual stenosis or nerve compression; (2) moderate disc degeneration at L3-4 with retrolisthesis, bulging, and facet hypertrophy causing mild stenosis without nerve compression; (3) disc degeneration at L2-3, with large marginal osteophytes; (4) retrolisthesis and disc bulging at both L2-3 and L1-2, with mild flattening of the thecal sac but no stenosis or nerve compression; and (5) inflammatory changes along the upper right SI joint and left SI joint.

On January 14, 2002, the insurer=s claims associate Thomas Koski wrote a hand-written note to Mr. Olson, stating, ASince April of 2001 your treatment[s] total 13. Please comply with t[he] workers[=] compensation treatment parameters 5221.6200[,] Subpart 3.@^[1] Mr. Olson responded on January 28, 2002, acknowledging that the employee=s passive care had exceeded the twelve-week durational limit provided by the treatment parameters. Mr. Olson noted, however, that the employee had been declared permanently and totally disabled and that the employee=s passive care had resulted in improvement or maintenance of his functional status. At the conclusion of his letter, Mr. Olson stated as follows:

This addresses all the points under 5221.6200 subpart 3. Patient has deviation from parameters relative to his long-term history and his consistent problems and his overall care. . . . . Please comply with worker=s compensation response of Minnesota Rule 5221.6050, subpart 9, C. If treatment is denied, please comply with Minnesota Rule 5221.6050, subpart 7, B.

Mr. Koski responded on January 31, 2002, asserting that there was essentially no medical support for continued physical therapy and that, A[u]nless you have up to date substantiation from a treating medical physician requesting and/or authorizing further physical therapy I will not be able to continue payment.@ On February 26, 2002, Mr. Olson responded, noting that Mr. Koski had apparently shifted the basis of his denial of coverage from the treatment parameters to the medical support issue and asserting that, as neither of these notices or issues was sent to the employee himself, he was forwarding Mr. Koski=s letters to the employee, the employee=s attorney, and Dr. Bocklage. Mr. Olson completed his letter by reiterating that the employee=s Acare is regularly reviewed by Dr. Bocklage and his care is certified as medically necessary by Dr. Bocklage=s order for physical therapy.@ The insurer evidently did not respond to this letter but apparently ceased paying for the employee=s physical therapy by the end of May 2002.

I don=t know that there is anything else that I can add to [the employee=s] care. I think he has got to stay with that pain rehabilitation center because I think that=s his lifeblood at this time.

If we can get some kind of pain control, which doesn=t seem to be effective right now, I think we can help him some, but he is getting pretty desperate at this time and I hope that he doesn=t do anything unreasonable because he is getting to the end of his tolerance.

On November 4, 2002, the employee filed a request for certification of a dispute concerning his physical therapy with Mr. Olson, and on November 20, 2002, he filed a Medical Request, seeking payment for that therapy, together with related mileage expenses. A medical conference was held, and on February 11, 2003, a compensation judge issued a Decision and Order ordering the employer and insurer to pay for the therapy and associated mileage, subsequently amending that decision and order on February 26, 2003, for clarification.

On March 12, 2003, the employer and insurer filed a Request for Formal Hearing, and the matter came on for hearing before a compensation judge on May 15, 2003. Issues at hearing included the employee=s entitlement to payment of $3,600.00 in physical therapy expenses incurred between June 12, 2002, and April 29, 2003, together with $194.18 in related mileage expenses. Implied subissues included whether the therapy at issue was reasonable and necessary and whether it was within applicable treatment parameters. The employee testified at hearing in part that his therapy with Mr. Olson made him feel Aa lot better,@ that because of that therapy AI get a better quality of life, I=m more functional, I can do more things.@ He testified that he normally begins each treatment session at about a level six to eight on a pain scale of one to ten, that he Acan go down to a five@ upon completion of the session, and that AI don=t know where I=d be without it, I don=t even want to think about it.@ He testified also that he would normally get from four to six days of relief from each treatment before his symptoms would start to return, conceding on cross-examination that Ait=s just kind of a cycling thing.@ He testified that his condition got Adramatically worse@ during a several-month period in 1995 when treatment was temporarily denied and that, although subsequent treatment has temporarily relieved his condition, over the years A[i]t=s been getting worse@ again.

By findings and order filed June 17, 2003, the compensation judge denied the employee=s claims, concluding that the treatment at issue was neither reasonable and necessary nor within the treatment parameters contained in Minnesota Rules 5221.6010, et seq. The judge also found expressly that the employer and insurer had not waived those parameters, that they had given the employee adequate notice of them, that departure from those parameters was not appropriate in this case, that this case did not qualify for a Arare case exception@ under Asti v. Northwest Airlines, 588 N.W.2d 737, 59 W.C.D. 59 (Minn. 1999), and that payment for related mileage was therefore also not compensable. The employee appeals.

In reviewing cases on appeal, the Workers= Compensation Court of Appeals must determine whether Athe findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. ' 176.421, subd. 1 (1992). Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Id.

The compensation judge found that the physical therapy at issue was neither reasonable and necessary treatment for the employee=s work injury nor within the applicable treatment parameters. The employee contends that the judge erred in both of these conclusions. He contends (1) that there is uncontroverted medical evidence that the therapy at issue was reasonable and necessary, (2) that the treatment parameters should not have been available to the employer and insurer as a defense because of those parties= own failure to comply with the parameters= notice and review provisions, (3) that, even if the parameters do apply, the judge erred in finding the employee=s treatment excessive under the parameters, and (4) that, to the extent that the therapy at issue might be deemed to exceed those parameters, the employee is nevertheless entitled to payment for the treatment by virtue of the departure provisions contained in the parameters themselves and the Arare case exception@ provisions established in the supreme court=s decisions in Jacka v. Coca Cola Bottling Co.^[2] and Asti v. Northwest Airlines.^[3] We are not persuaded.

At Finding 9, the compensation judge found expressly that A[t]he employer and insurer gave adequate notice of the treatment parameters,@ explaining that A[t]he treatment parameters in Minn. Rule 5221.6200, subp. 3, were specifically cited in the insurer=s letter of January 14, 2002. Clearly, the treatment parameters were not waived by the employer and insurer.@ The employee argues that the compensation judge committed reversible error when he applied the treatment parameters in this case. Citing Dawson v. University of Minnesota, slip op. (W.C.C.A. May 6, 1999), and Minn. R. 5221.6050, subps. 7B and 9C, the employee contends that the treatment parameters are presumed waived as a defense for an employer and insurer who do not comply with all of the notice provisions of the parameters and that no showing of full compliance was made in this case. We are not persuaded that the employer and insurer=s compliance with the notice provisions was insufficient.

The compensation judge suggested that the January 14, 2002, note from the insurer=s claims adjuster Mr. Koski to therapist Mr. Olson constituted adequate notice of the insurer=s intent to invoke the durational limits for passive care provided by the treatment parameters. In their responsive brief, the employer and insurer acknowledge that Mr. Koski did not, in his note of January 14, 2002, inform Mr. Olson that the treatment parameters permit departure in certain circumstances, as is arguably required under the parameters. They also note accurately, however, that Mr. Olson=s response to Mr. Koski Aaddressed a deviation from the parameters, indicating [that Mr. Olson] was already aware of the rules allowing a departure from durational limitations.@ Further, although it is obvious from Mr. Olson=s responses to the insurer that he believed that treatment for the employee should continue, Mr. Olson=s letters did not include notification of an intent to depart from the parameters, as would arguably be required of the provider under the parameters. It would appear that neither the employer and insurer nor the health care provider technically complied with all of the requirements of the notification provisions set forth in Minn. R. 5221.6050, subps. 7B and 9, which address the notice responsibilities of the insurer and the health care provider, respectively. Both the employee and his attorney were evidently kept informed of the correspondence between Mr. Olson and Mr. Koski. Under the facts of this case, we believe that substantial evidence supports the judge=s finding that notice was adequate in this case and that the employee=s treatment was therefore subject to the treatment parameters. See Riendeau v. Wal-Mart, 61 W.C.D. 811, 821 (W.C.C.A. 2001) (A[t]he treatment parameters remain guidelines, and, although their notice provisions may not be ignored, [citation omitted], a good faith effort to comply with their technicalities may be sufficient@).

Minn. R. 5221.6200, subp. 3A, provides that passive treatment is generally limited to twelve weeks, except as provided in subpart 3B of that rule, and it is uncontested that the employee=s physical therapy with Mr. Olson exceeded that duration. Subpart 3B of that rule provides in toto as follows:

B. (1) An additional 12 visits for the use of passive treatment modalities over an additional 12 months may be provided if all of the following apply:

(a) the employee is released to work or is permanently totally disabled and the additional passive treatment must result in progressive improvement in, or maintenance of, functional status achieved during the initial 12 weeks of passive care;

(c) the health care provider must document in the medical record a plan to encourage the employee=s independence and decreased reliance on health care providers;

(d) management of the employee=s condition must include active treatment modalities during this period;

(e) the additional 12 visits for passive treatment must not delay the required surgical or chronic pain evaluation required by this chapter; and

(2) Except as otherwise provided in part 5221.6050, subpart 8, treatment may continue beyond the additional 12 visits only after prior approval by the insurer, commissioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining employability; if the employee is permanently totally disabled, or if upon retirement the employee is eligible for ongoing medical benefits for the work injury, treatment may continue beyond the additional 12 visits only after prior approval by the insurer, commissioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status.

It is acknowledged that the employee=s therapy with Mr. Olson has exceeded twelve weeks. In his memorandum, the compensation judge supported as follows his conclusion that the employee did not qualify for an additional twelve visits under Minn. R. 5221.6200, subp. 3B:

The employee does not meet the requirements of paragraph B for an additional 12 visits because, among other reasons, the treatment was being given on a regularly scheduled basis, a plan to encourage independence and decreased reliance on health care providers is not documented, and it is likely that the employee has chronic pain syndrome. The court is not persuaded by a preponderance of the evidence that additional passive treatment is effective in maintaining functional status. Despite the employee=s testimony, the treatment appears to have little significant impact on functional status. In fact, the employee is gradually getting worse and cannot even get hot packs or massage as part of the physical therapy at the present time.

The employee contends that, pursuant to Minn. R. 5221.6200, subp. 3B(2), passive treatment may continue beyond the presumptively allowed twelve weeks plus twelve visits, Abased on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status.@ He contends that the records of Dr. Bocklage, Dr. Hess, and Mr. Olson, in addition to the testimony of the employee, all support the conclusion that the employee=s physical therapy is effective in maintaining the employee=s functional status. In support of his position, the employee relies primarily on elements of his own testimony, referencing no specific records of Dr. Hess or Mr. Olson and citing only Dr. Blockage=s letter of November 22, 1993, for the general proposition that AMr. Olson=s treatment is the only form of treatment which has helped Employee.@ We are not persuaded.

While there are indeed several referral slips of record by which Dr. Blockage referred the employee for additional physical therapy, only half of the handful of actual treatment records of Dr. Bocklage=s care that are cited by the employee in support of his position pertain to the period of therapy here at issue, and only a single one of those recordsBan office note for October 10, 2002--expressly addresses the employee=s care at a facility referred to by the doctor as Athat pain rehabilitation center,@ which the doctor calls the employee=s Alifeblood.@ While it might be conceivable that the latter is a reference to the therapy of Mr. Olson, as the employee has suggested, it appears to us far more probable that it is a reference to the employee=s chronic pain treatment at the United Pain Center with Dr. Hess, whom Dr. Bocklage referred to on December 7, 2000, as Athe main person for [the employee=s] pain.@ Moreover, the employee himself testified that his relief with the physical therapy at issue was only Ajust kind of a cycling thing@ usually lasting only about four to six days, that even that relief was normally only a reduction from about a level six to eight pain on a one-to-ten scale to a level five pain on that scale, and that his pain has, after all, Abeen getting worse@ over the years. Nor do Mr. Olson=s own records during the period of the treatment here at issue reflect any more substantial effectiveness. In light of this record, we conclude that it was not unreasonable for the compensation judge to conclude that the employee has not demonstrated Athe effectiveness of further passive treatment in maintaining functional status,@ as would be required under Minn. R. 5221.6200, subp. 3B(2). Therefore we affirm the judge=s decision to that extent. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.

The employee had requested a departure from the requirements of the Treatment Parameters, based on provisions of Minn. R. 5221.6050, subp. 8, which provides at paragraph A that a departure may be appropriate A[w]here there is a documented medical complication.@ The compensation judge denied the request, explaining in his memorandum as follows:

The fact that the employee has a complicated medical situation, which includes four surgeries, does not justify long-term physical therapy that is providing little overall benefit. It would not be a reasonable interpretation of the treatment parameter rules to hold that whenever any kind of medical complication can be shown, there is no longer any limit on the amount of medical treatment that can be provided. A more reasonable interpretation of the rule is that when there is a documented medical complication, the court may grant some additional medical treatment if it is reasonable and necessary to treat the medical complication. The court does not find that over 20 years of physical therapy is reasonable or necessary in this case. As far as the other departure provisions of Minn. Rule 5221.6050, Subp. 8, the employee does not even arguably meet paragraphs B-E.

Basing his argument on paragraph A of subpart 8, that he is subject to Aa documented medical complication,@ the employee contends on appeal that he

has had an unsuccessful result from his four surgeries. He has been left with what can fairly be described as one of the worst low backs one can imagine. He walks with a pronounced limp. He experiences frequent exacerbations of his condition resulting in significant muscle spasm and pain. He has been permanently and totally disabled since 1984. His condition is indisputably far more complicated than that contemplated by the drafters of the treatment parameters.

We can find nothing in the employee= argument that is not addressed by the factual conclusion most recently quoted above from the compensation judge=s memorandum, which we cannot, in turn, find unreasonable in light of the all of the evidence of record. Because it was not unreasonable in light of the entire record, we affirm the compensation judge=s factual conclusion that the employee did not satisfy the departure provisions of Minn. Rule 5221.6050, subp. 8A.

4. ARare Case Exception@ from the Parameters / Reasonableness and Necessity of the Therapy

In Jacka v. Coca Cola Bottling Co., 580 N.W.2d 27, 58 W.C.D. 395 (Minn. 1998), the supreme court authorized compensation judges to depart from the treatment parameters even aside from the departures permitted under the rules themselves, Ain those rare cases in which departure is necessary to obtain proper treatment.@ Jacka v. Coca Cola Bottling Co., 580 N.W.2d 27, 35-36, 58 W.C.D. 395, 408 (Minn. 1998). This Arare case exception@ was subsequently applied and expanded in Asti v. Northwest Airlines, 588 N.W.2d 737, 59 W.C.D. 59 (Minn. 1999), in which the court observed that A[i]t cannot be legitimately asserted that the drafters of the treatment parameter rules considered every possible scenario, yet determined that the wiser choice was to require the employee=s health to decline to the point of inability to work rather than to continue an inexpensive treatment that allows continued employment.@ Asti v. Northwest Airlines, 588 N.W.2d 737, 740, 59 W.C.D. 59, 64 (Minn. 1999). In his memorandum, the compensation judge in the present case concluded that

[t]his case is clearly not the type of situation that would fall under the Arare case exception@ contemplated by Asti v. Northwest Airlines, 588 N.W.2d 737 (Minn. Sup. Ct. 1999). In Asti, the court determined that a departure from the treatment parameter rules was necessary in order to obtain proper medical care that would allow the employee to continue working. Here, not only is the physical therapy not proper medical care, but the employee is unable to work in any event.

On appeal, the employee reiterates the severity of his low back condition, arguing that his providers have tried Aevery form of treatment imaginable@ and have settled upon physical therapy, in addition to medications, as the only appropriate means of providing the employee with the maximum relief of his symptoms and maintenance of his functional status. The employee acknowledges that A[o]ngoing physical therapy at the frequency and duration which has been received by Employee is certainly unusual,@ but he contends that it is nevertheless Ajustified by Employee=s unusually bad injury.@ We are not persuaded.

A compensation judge=s conclusion as to whether or not an employee=s condition qualifies as a Arare case exception@ to the treatment parameters is to be reviewed pursuant to the HengemuhleAsubstantial evidence@ standard. See Pawlitschek v. Dundee Steel, Inc., slip op. (W.C.C.A. Sep. 7, 1999). Moreover, any treatment that would be compensable under a Arare case exception,@ however severe might be the employee=s conditionBand certainly the employee in this case is severely disabled--must be reasonable and necessary treatment. Id. At Finding 5, the compensation judge in the present case concluded that the treatment here at issue was not reasonable and necessary treatment, and in his memorandum the judge explained that conclusion as follows:

There was not a reasonable treatment plan. It is not clear what the goals and objectives for the treatment were and it is not clear how the treatment would be modified if the goals and objectives were not met. The details of the treatment were not well documented in the records. The treatment notes are pretty similar from week to week. The treatment was provided on an essentially regular basis. Even though the treatment was authorized by Dr. Bocklage, there appears to have been very little monitoring of the treatment. Although the employee testified to considerable benefit from the treatment, the court finds that the degree and duration of relief was not very much. There has been no long term improvement from the treatment; rather, the employee=s condition is gradually getting worse. In fact, the employee is not even getting hot packs and massage anymore because of his condition and he is unable to do most of the exercises. There has been little effort made to increase the employee=s independence and decrease his reliance on physical therapy. There is a risk of psychological dependence on the treatment, especially in light of the lengthy period of treatment and the lack of significant results.

It is apparent from this explanation that the compensation judge is basing his assessment on well established case law factors perhaps best summarized in the cases of Field-Seifert v. Goodhue Co., slip op. (W.C.C.A. Mar. 5, 1990), and Horst v. Perkins Restaurant, 45 W.C.D. 9 (W.C.C.A. 1991).

The judge=s factual conclusion and its bases would appear to be well supported by substantial evidence. The employee contends, however, that the compensation judge erred as a matter of law by rejecting what he characterizes as uncontroverted medical opinion. He acknowledges case law establishing that unopposed medical opinion may not necessarily be binding on a trier of fact so long as it is not ignored. See Tuomela v. Reserve Mining Co., 299 Minn. 203, 204, 216 N.W.2d 638, 639, 27 W.C.D. 312, 313 (1974). He argues, however, that this principle applies only in cases where the issue is work causation of the condition at issue, not in cases where the issue is the reasonableness and necessity of specific medical treatment for that condition, which he contends must be the province only of medical experts. Here, the employee contends, the judge erred in rejecting treatment ordered by Dr. Bocklage, approved by chronic pain specialist Dr. Hess, and provided by Mr. Olson, a certified physical therapist. We are not persuaded.

Regardless of whether it is governed by the treatment parameters or analyzed under Minn. Stat. ' 176.135 and long-standing case law principles, the reasonableness and necessity of any given medical treatment is a question of fact for the compensation judge. See Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993). In this case, the judge analyzed the disputed treatment under case law principles and under the guidelines of treatment parameters specifically enacted to aid the trier of fact in determining appropriate treatment. In our view, the issue is not whether the judge rejected uncontroverted medical opinion but whether there exists in the record substantial evidence supportive of the judge=s factual determination. We conclude that substantial evidence in the record supports the judge=s finding that the treatment at issue was not reasonable and necessary to cure or relieve the effects of the work injury, and, accordingly, that finding is affirmed. Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.

In light of our affirmance of the judge=s conclusion as to the reasonableness and necessity of the therapy at issue, we affirm the judge=s conclusion that the employee=s condition does not qualify as a rare case exception to the treatment parameters under the Jacka and Asti cases. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.

^[1] Minn. R. 5221.6200, subp. 3, addresses the use of passive treatment modalities for the treatment of low back pain.

^[2] 580 N.W.2d 27 (Minn. 1998).

^[3] 588 N.W. 2d 737 (Minn. 1999)