In Order for A Claim for Treatment to Be Compensable, It Must Be Medically Necessary and Causally Related to A Work Injury

Soto v. Exclusive Coachworks, Inc.

Docket No. A-2331-19

Decided April 12, 2021

Submitted by New Jersey Workers’ Compensation Lawyer, Jeffrey Hark.

In a recent unpublished decision, the New Jersey Appellate Division reviewed whether a knee replacement was compensable under workers’ compensation when the petitioner had two prior knee surgeries that were not work related.

In Soto, Petitioner, who was employed by respondent as an autobody repairman, was injured on October 3, 2017, when a hammer struck the inside of his left knee. Because petitioner was unable to walk, his employer instructed him to go to the emergency room. On October 5, 2017, emergency room (ER) physicians performed an x-ray. There was no evidence of acute fracture or dislocation; however, there was a small suprapatellar effusion. The ER doctor instructed him to follow up with an orthopedic surgeon.

On October 10, 2017, petitioner, on his own accord, went to Dr. Robin Innella, who sent him for an MRI.1 After reviewing the MRI, Dr. Innella diagnosed petitioner with a torn meniscus as well as a trabecular bone injury in his left knee. Dr. Innella recommended petitioner undergo an arthroscopic surgery to his left knee.

The worker’s compensation carrier referred petitioner to two other orthopedists, Dr. Thomas Nordstrom and Dr. Wayne Colizza, both of whom agreed that arthroscopic surgery was medically necessary and causally related to the October 3, 2017 workplace injury. On July 13, 2018, Dr. Colizza performed an authorized arthroscopy of the left knee and partial meniscectomies. After the surgery, however, petitioner’s condition did not improve, despite additional conservative treatment including physical therapy and injections. Dr. Colizza initially opined that the work injury and the subsequent surgery “accelerated” petitioner’s need for a total knee replacement but changed his position after reviewing records from petitioner’s prior medical treatments.

On April 26, 2019, petitioner filed a motion for medical and temporary disability benefits seeking authorization for a left knee replacement and temporary benefits retroactive to January 2019. The judge of workers’ compensation found that the knee replacement was indeed medically necessary and causally related to the 2017 injury.  This was after taking testimony from petitioner’s expert, who was not a treating physician for petitioner, and respondent’s expert who was the treating physician.  Even though the respondent’s expert opined the knee replacement was not related to the 2017 injury, the workers’ compensation judge agreed with petitioner’s expert that it was related.

Respondent appealed and the Appellate Division affirmed and found that there was adequate evidence contained in the record to support the workers’ compensation judge’s conclusion that the total knee replacement was medically necessary and causally related to the 2017 injury.

In order for a claim for treatment to be compensable, it must be medically necessary and causally related to a work injury.  This is shown through expert testimony by a doctor opining that by a reasonable degree of medical certainty the treatment is medically necessary and the injury was the result of the workplace injury. Usually the expert is a treating physician, as they have personal knowledge of the petitioner’s ailments. However, as shown above, that is not an absolute necessity, and a petitioner can use a nontreating physician to opine as to these requirements.

If you or someone you know has been injured on the job, you need to make sure you contact a workers’ compensation attorney with experience today.  These attorneys can answer all of your questions regarding temporary benefits, medical bill payments, permanent injury, and the nuances of workers’ compensation law.  Do not hesitate to contact Hark & Hark today to discuss your personal injury.

For workers’ compensation and personal injury matters, you pay nothing upfront, and our fee is paid as a percentage of your recovery. At Hark & Hark, we represent clients for any case in any county in New Jersey including Atlantic, Burlington, Camden, Cape May, Cumberland, Essex, Gloucester, Mercer, Ocean, and Salem counties. We represent clients in all towns in New Jersey, including Newark, Jersey City, Paterson, Elizabeth, Edison, Woodbridge, Lakewood, Toms River, Hamilton, Trenton, Clifton, Camden, Brick, Cherry Hill, Passaic, Middletown, Union City, Old Bridge, Gloucester Township, East Orange, Bayonne, Franklin Township, North Bergen, Vineland, and Union.