The self-insured employer appeals from the compensation judge’s award of lodging expenses to intervenor Bryan Lee and day care expenses to intervenor Melvin McGowan, and the judge’s finding that the employee’s treatment with Dr. Falconer at Summit Orthopedics was not an unauthorized change of physicians.  We affirm in part and reverse in part.

The employee lives in Perham, Minnesota, about 180 miles from the Twin Cities.  On October 12, 2007, while cleaning a piece of dough from the potato chip line, the employee’s right hand and forearm were caught in the conveyor belt and crushed between two rollers.  The employee was airlifted to North Memorial Medical Center in Robbinsdale, Minnesota.  She was seen in the emergency room and was then examined by Dr. Brian O’Neill, an orthopedic surgeon, who diagnosed an open fracture of both forearm bones, extensive soft tissue injuries, and a basilar thumb metacarpal fracture.  Dr. O’Neill performed extensive skin and muscle debridement and open reduction internal fixation (ORIF) of the forearm fractures.  Dr. David Ruebeck, a plastic surgeon, then performed percutaneous pinning of the thumb fracture and repaired muscles of the forearm.  On October 14, Dr. Ruebeck performed additional skin and muscle debridement and wound closure with a graft from the employee’s thigh.  She was discharged from the hospital on October 18, 2007.  Upon her release, the employee remained in the Twin Cities area, residing with intervenor Bryan Lee and Wendy McGowan in Forest Lake, Minnesota, while obtaining continuing medical care and treatment.

On October 23, 2007, the employee began treatment at NovaCare Rehabilitation upon referral by Dr. Ruebeck.^[1]  On November 13, 2007, Dr. Ruebeck noted the employee was doing hand therapy three times a week in addition to a home program.  The employee was seen by Dr. O’Neill the following day who indicated the bone forearm fracture implants were in good position.  On December 11, 2007, Dr. Ruebeck stated the employee would be off work for another 2 to 4 months at least while continuing her hand and thumb therapy.  Dr. O’Neill noted some pain with gentle motion, but stated the wound looked good and the employee could start moving her wrist.  On January 8, 2008, Dr. Ruebeck recorded an improvement in wrist range of motion but noted significant extensor lag in the index and ring fingers.  X-rays also showed the thumb pins had loosened.  Dr. Ruebeck recommended the employee continue therapy three times per week along with external splinting and use of a bone stimulator.  He stated the employee could now drive, and also provided a referral for a psychological evaluation.  On that same date, Dr. O’Neill noted the forearm fractures appeared to be consolidating and recommended the employee continue to work on range of motion.

On February 12, 2008, Dr. Ruebeck noted continuing extensor lag in the fingers and on March 26, 2008, performed a third surgery, an extensor tenolysis of the right index and ring fingers.  On April 1, 2008, Dr. Ruebeck noted the tendons were in good shape and the employee’s range of motion had improved.  He recommended she continue with hand therapy three times per week plus the home program, and continued the employee off work for one month.  The employee was seen by Dr. O’Neill the following day.  He observed the employee’s fractures were well-healed, but did not believe she had reached maximum medical improvement for her injury.

On April 8, 2008, Dr. Ruebeck recommended the employee continue with hand therapy for another six weeks.  At the May 13, 2008, visit, Dr. Ruebeck noted the employee had made gains, but had permanent loss of function.  The doctor recommended the employee remain off work until a functional capacities evaluation (FCE) could be completed.  The employee moved back to Perham around the middle or end of May 2008.  (T. 98.)  The employee was seen again by Dr. Ruebeck on July 29, 2008. ^[2]

On January 13, 2009, the employee was seen by Dr. Richard Strand, an orthopedic surgeon, at the request of the self-insured employer.  The employee reported some tightness and aching in her right hand, but indicated she was not in pain and could do normal activities of daily living.  The doctor opined the employee’s right hand complaints were not supported by objective findings, that the surgeries had been successful resulting in excellent function of the right hand, and that the employee required no further treatment related to the work injury.  In Dr. Strand’s opinion, the employee reached maximum medical improvement as of July 29, 2008, had a 5% permanent partial disability for limited wrist range of motion, and could return to work without restrictions.

On February 17, 2009, Dr. Ruebeck concluded it was reasonable for the employee to return to work with the employer in a medical modified work assignment.  He recommended a work-hardening program followed by an FCE to determine permanent restrictions.

On June 7, 2009, Dr. Ruebeck completed a Health Care Provider Report in which he opined the employee would reach maximum medical improvement as of June 23, 2009.  Dr. Ruebeck released the employee to light-duty work on June 23, 2009, with restrictions consistent with an FCE completed on June 8, 2009.  The doctor noted the employee’s hands were still weak and recommended a health club membership and additional occupational therapy.

The evidence shows a gap in treatment from June 2009 to February 2015.  The employee testified she had not seen either Dr. Ruebeck or Dr. O’Neill since 2009.  (T. 113-14, 119.)  She stated she began having problems with her right hand in November 2014 and saw her family practitioner, Dr. Corey Nyhus, in December 2014.  (T. 108, 114, 132.)  On February 26, 2015, Dr. Nyhus noted increased scarring and swelling of the right wrist resulting in contracture of the fingers.  In his opinion, an evaluation by a hand specialist was necessary and he referred the employee to Dr. David Falconer at Summit Orthopedics.

Dr. Falconer examined the employee on March 23, 2015.  The doctor took a history of the October 2007 injury and subsequent treatment.  He noted current complaints of burning pain, reactive swelling, and increased sensitivity with use, as well as stiffness, locking, discomfort, and loss of motion.  Dr. Falconer concluded plates and screws from the 2007 surgery were likely causing irritation of the underlying tendon structure.  The doctor recommended an EMG to rule out a nerve problem and likely hardware removal.

In November 2013, the employee filed a Medical Request seeking reimbursement of medical-related expenses incurred between October 2007 and January 2008.  Bryan Lee and Melvin McGowan subsequently intervened seeking reimbursement for lodging and child care expenses.  The employee filed a Request for Formal Hearing on May 9, 2014, following an administrative decision denying the claims.  On January 26, 2015, the employee filed a second Medical Request seeking approval of treatment with Dr. Falconer.  In a Findings and Order served and filed May 27, 2015, the compensation judge ordered the self-insured employer to pay for the employee’s care with Dr. Falconer.  The judge also awarded the claims of intervenors Bryan Lee and Melvin McGowan for lodging and child care expenses.  The self-insured employer has appealed.

On appeal, the Workers’ Compensation Court of Appeals must determine whether “the 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.  Substantial evidence supports the findings if, in the context of the entire record, “they 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, findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.”  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).

Intervenor Bryan Lee is the significant other of Wendy McGowan, the employee’s former sister-in-law.  The employee resided with Lee and McGowan in Forest Lake following her October 2007 work injury.  The compensation judge awarded Mr. Lee $5,675.00 for lodging provided to the employee from October 18, 2007, through February 29, 2008.^[3]  The compensation judge found it was not practical for the employee to live in Perham and commute multiple times per week for essential medical care in the Twin Cities.  The judge further found that $50 per day for lodging in the Twin Cities was a reasonable charge.  The compensation judge reasoned that had the employee not been able to stay with Mr. Lee and Ms. McGowan in the weeks and months following her work injury, she likely would have had to live in a hotel or a transitional care facility, and that any commercial options would have been more costly than the $50 per day sought by Bryan Lee.  (Findings 3, 4, 9; Mem. at 6.)

The employer argues the compensation judge failed to cite any statute, rule, or case law establishing the compensability of lodging expenses in such circumstances.  The appellant urges this court to apply Minn. R. 5221.0500, subp. 2.E., which reads, in part:

Minnesota case law provides little guidance on this issue.  However, in our opinion, Minn. R. 5221.0500, subp. 2.E., is not applicable in this case.  Rule 5221.0500, governs excessive charges by health care providers such as physicians, chiropractors, psychologists, psychiatric social workers, and the like.  See Minn. Stat. § 176.011, subd. 12a; Minn. R. 5221.0100, subps. 12, 15.  Additionally, subpart 2.E. refers to “travel expenses.”  The language of the rule indicates its purpose is to limit charges for the cost of travel to and from medical treatment.  Arguably, the section refers to medical mileage and not expenses such as room and board.  Compare, e.g., Minn. R. 5220.0410, subp. 11, Travel Expenses (the insurer shall reimburse the employee for “automobile mileage” at the rate paid by the state of Minnesota under the commissioner’s plan for employment-related travel.)

The appellant does not explicitly reject the compensability of all lodging expenses, but rather appears to assert the employee should have incurred a greater expense by lodging at a licensed lodging facility such as an extended stay hotel or transitional care facility, rather than with Mr. Lee and Ms. McGowan.  The employer admits “the employee received extended treatment outside her immediate geographic region.”  (App. Brief p. 8.)  The evidence supports the judge’s conclusion that from October 2007 to May 2008, the frequency of the employee’s medical visits and therapy required her to temporarily relocate to the Twin Cities from her home in Perham.  (T. 98-100.)  The employee testified she looked into alternative living arrangements, including motels used by NovaCare or Dr. Ruebeck, and the cost was at least $85.00 per day, a cost she could not afford.  (T. 120-21.)

Based on the record as a whole, the compensation judge could reasonably conclude that the lodging provided by intervenor Lee, from October 18, 2007, to February 29, 2008,^[4] was a reasonably necessary service required by the employee for medical care prescribed to cure and relieve from the effects of her injury.  Minn. Stat. § 176.135, subd. 1.  We, accordingly, affirm.

The employee was a single parent with a 16-year-old son at the time of the injury.  While the employee was receiving medical treatment in the Twin Cities, her 16-year-old son lived with the employee’s father, Melvin McGowan and his wife in Perham.  Mr. McGowan sought reimbursement of $2,400.00, representing $50.00 per day, for care of the employee’s son.  The compensation judge awarded the requested child care expenses to intervenor McGowan, finding the requested expense was reasonably necessary to facilitate reasonable and necessary medical care.  (Findings 6, 7.)

The compensation judge acknowledged the Workers’ Compensation Act provides for payment of child care costs only as a rehabilitation benefit when an employee is looking for work or is receiving retraining.^[5]  See Minn. Stat. § 176.102, subd. 9.  The compensation judge, however, awarded reimbursement as a medical benefit citing Volner v. Cub Foods, 41 W.C.D. 319 (W.C.C.A. 1988), concluding the case remains good law.  In Volner, day care expenses were awarded while an injured employee attended an inpatient pain clinic program as part of her rehabilitation plan.  Since Volner, Minn. Stat. § 176.102, subd. 9, has been amended to specifically exclude physical rehabilitation from rehabilitation services under section 176.102.

More to the point, both this court and the supreme court have held that Minn. Stat. § 176.135, subd. 1, does not provide for the payment of child care expenses incurred while an employee is undergoing medical care and treatment.  Langa v. Fleischmann-Kurth Malting Co., 481 N.W.2d 35, 46 W.C.D. 156 (Minn. 1992); Ryks v. Control Data, slip op. (W.C.C.A. June 4, 1990).  We, therefore, reverse the award of child care expenses to intervenor McGowan.

The compensation judge concluded the employee’s treatment with Dr. Falconer did not constitute an unauthorized change of physician and ordered payment for treatment rendered at Summit Orthopedics prior to the hearing.  (Finding 18, Order 4.)  Whether a change of physician is appropriate is a question of reasonableness under the circumstances of each case.  Hernandez v. Heartland Foods, 53 W.C.D. 372, 378 (W.C.C.A. 1995).

Minn. R. 5221.0430 governs a change of health care provider.  The definition of a primary health care provider under Minn. R. 5221.0430, subp. 1, presumes an ongoing relationship with continuing medical treatment provided to the employee directed or coordinated by the health care provider.^[6]  McCoy v. Hennepin Home Health Care, slip op. (W.C.C.A. May 23, 2007).  The compensation judge found the employee had no ongoing treatment relationship with Drs. O’Neill and Ruebeck after 2009.  Because of the lapse in treatment between 2009 and the employee’s referral to Dr. Falconer in 2015, the compensation judge concluded the employee no longer had a primary health care provider as contemplated by the rule, and the treatment with Dr. Falconer in 2015 did not constitute an unauthorized change of physician.  There is substantial evidence to support the compensation judge’s determination and we affirm.

The self-insured employer also asserts that regardless of whether approval of the change of physician was appropriate, the compensation judge erred in awarding medical expenses incurred at Summit Orthopedics for the employee’s treatment with Dr. Falconer prior to the hearing because, under Minn. R. 5221.0430, subp. 3, an insurer is not liable for treatment rendered prior to the approval.^[7]

We disagree.  The compensation judge concluded the employee was without a primary health care provider in 2015 as defined in Minn. R. 5221.0430, subp. 1.  The employee’s treatment with Dr. Falconer was not a change of physician within the meaning of the rule and, therefore, no prior approval for the change was necessary.  Moreover, assuming approval was required, under subpart 2 of the rule a compensation judge may approve a change of primary care physician.  Although an employer or insurer need not pay for pre-approval medical care prior to approval of an employee’s request to change physicians, they may be ordered to pay for prior reasonable and necessary treatment once approval is granted by a compensation judge.  Henschel v. Interfaith Social Servs., slip op. (W.C.C.A. Oct. 2, 1995).  We affirm.