WILLIAM JOHNSON, Employee/Respondent, v. DARCHUKS FABRICATION, INC. and HARLEYSVILLE INS., Employer-Insurer/Appellants, and INJURED WORKERS PHARMACY, Intervenor.

The employer and insurer appeal the compensation judge’s refusal to apply the treatment parameters on opioid medication. Because the employer and insurer maintained that the employee’s complex regional pain syndrome (CRPS) condition had resolved and that the medication was neither necessary nor reasonable, the treatment parameters do not apply to limit payment for the medications in dispute.

On September 4, 2002, the employee, William Johnson, was working for the employer when he rolled his right ankle after stepping on a piece of scrap tubing. The employee suffered a severe ankle injury, including an avulsion fracture of the talus. The employee was taken off of work and began treatment for his injury. The employee’s condition did not improve. On March 10, 2003, the employee was examined by Mark Stuckey, M.D., at the Fairview University Medical Center. Dr. Stuckey documented symptoms consistent with sympathetic dystrophy. By June 2003, the employee was diagnosed with CRPS and hammer toes on his right foot. On August 23, 2004, the employee was examined by Harry G. Miller, M.D., who noted that the employee was caught between being in extreme pain or enduring the side-effects of opioid medication due to the employee’s intractable CRPS condition. Dr. Miller indicated that surgery was not an option to address the employee’s pain condition.

On June 18, 2004, the employee underwent an independent medical examination (IME) conducted by John Dowdle, M.D., on behalf of the employer and insurer. Dr. Dowdle diagnosed reflex sympathetic dystrophy (RSD) and noted that amputation was being considered to address the employee’s pain symptoms. Dr. Dowdle suggested an open sympathectomy as an alternative to addressing those symptoms. (Employer’s Ex. 6.) Two surgeons assessed the employee as a poor candidate for that procedure.

In 2005, the employee began treating with Gregory Sperle, M.D. Dr. Sperle continued pharmacological treatment to address the employee’s pain symptoms arising from the RSD condition. The employee’s pain medications included Endocet, an opioid, which supplanted the Oxycontin, Percocet, and methadone that had been previously prescribed.

On February 11, 2009, Matthew Monsein, M.D., completed a medical record review of the employee on behalf of the employer and insurer. Dr. Monsein considered the employee’s treatment, including Endocet and Neurontin, to be reasonable, necessary, and causally related to the employee’s work injury and resulting CRPS condition. The employee continued treating for pain using opioid medications.

On May 2, 2016, the employee underwent an IME conducted by Randal Wojciehoski, D.P.M., D.O., on behalf of the employer and insurer. Dr. Wojciehoski opined that the employee suffered from subjective complaints of pain that are out of proportion to any physical findings. Dr. Wojciehoski noted the absence of some of the CRPS/RSD symptoms and indicated that he was “not convinced” that the employee was experiencing that condition. Dr. Wojciehoski recommended that the employee be weaned off of opioid medications and benzodiazepines. In an addendum report dated July 11, 2017, Dr. Wojciehoski supplemented his earlier report and affirmatively maintained that the employee did not have CRPS, that his current opioid medication was not prescribed properly under the treatment parameters, and that the ongoing prescriptions of Lorazepam, nifedipine, and Neurontin were neither reasonable nor necessary to treat the employee’s chronic pain condition.

On July 21, 2016, the employer and insurer sent a letter to Dr. Sperle requesting compliance with Minn. R. 5221.6110. Dr. Sperle’s progress notes from October 14, 2016, indicate that the employee continued to experience most of the symptoms of CRPS and that the employee requires Endocet, cyclobenzaprine, and Neurontin to address those symptoms. Dr. Sperle supported referral of the employee to a pain clinic as a possible alternative to continuing the current prescription regimen.

The employee filed a medical request seeking payment for various medications, including Endocet. The employer and insurer filed a medical response claiming that the treatment was not reasonable or necessary to treat the employee and that the treatment parameters were not followed. The dispute was heard at the Department of Labor and Industry (DLI). Both parties filed requests for formal hearing on the DLI determination. The formal hearing was conducted by a compensation judge on July 21, 2017. The issues presented by the parties included: 1) whether the employee’s CRPS had resolved; 2) whether Endocet and two other medications were reasonable and necessary to treat that condition; and 3) whether the treatment parameters applied to the Endocet prescription.

The compensation judge heard testimony from the employee regarding his chronic paresthesias, hypersensitivity, intolerance to extreme heat and cold, skin atrophy, and increased pain with physical activity affecting both the right and left lower extremities.^[1] The judge also heard testimony from the employee regarding his use of Endocet, and the failure of substituting gabapentin for Neurontin.

The compensation judge found that the employee’s CRPS condition had not resolved, that the medications at issue were reasonable and necessary to cure and relieve the employee of the effects of the work injury, and that the treatment parameters were not applicable. In his memorandum, the compensation judge relied on the language in Minn. R. 5221.6020, subp. 2, that the treatment parameters were inapplicable after the insurer denied liability for the condition. The compensation judge awarded employee’s claims and ordered payment to an intervenor. The employer and insurer 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(3). 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).

A decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which the Workers’ Compensation Court of Appeals may consider de novo. Krovchuk v. Koch Oil Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993), summarily aff’d (Minn. June 3, 1993).

The treatment parameters are set out in Minn. R. ch. 5221. The language of Minn. R. 5221.6020, subp. 2, is unambiguous. Where liability is denied, the treatment parameters do not apply until after liability is established. The employer and insurer denied liability for the prescriptions by challenging causation of the condition at issue. Denial of medical causation in the form of resolution of the condition or independent causation of symptoms has been held to render the treatment parameters inapplicable under this rule. See Schulenburg v. Corn Plus, 65 W.C.D. 237, 248-49 (W.C.C.A. 2005), summarily aff’d (Minn. May 25, 2005); Oldenburg v. Phillips & Temro Corp., 60 W.C.D. 8, 13-14 (W.C.C.A. 1999), summarily aff’d, 606 N.W.2d 445, 446 (Minn. 2000); Mattson v. Northwest Airlines, slip op. (W.C.C.A. Nov. 29, 1999).^[2]

In this matter, both the resolution of the employee’s CRPS and the reasonableness of continued opioid treatment were set out as issues.^[3] The employer and insurer explicitly argued at hearing on four separate occasions that the employee recovered from his CRPS condition.^[4] The employer and insurer contend that their position in this matter does not constitute contesting liability. We disagree. The employee sought payment for the opioid medication and that request was denied. There is no special status in the rules that allows an insurer that accepts the occurrence of a work injury the ability to contest liability for the particular treatment sought while simultaneously asserting that the treatment parameters apply to limit payment for that treatment. See Pinc v. Stepping Out, Inc., 69 W.C.D. 181 (W.C.C.A. Mar. 6, 2009). A successful challenge to causation or reasonableness in this case would have resulted in a denial of liability for prescriptions in this matter. As the employer and insurer contested liability for the treatment sought, the plain language of Minn. R. 5221.6020, subp. 2, precludes application of the treatment parameters in that proceeding.

The compensation judge correctly applied the law to the facts in this case and the findings and order served and filed September 20, 2017, is AFFIRMED.