What Will Happen to Workers’ Comp if Luxury Beds Become ‘Reasonable and Necessary Medical Treatment’?

| | Utilization Review

sleep number

Who saw this one coming? In the recent case of Jared Carnes v. Auto Zone, the California Workers’ Compensation Appeals Board (WCAB) ruled that a $5,325 i8 Sleep Number bed was reasonable and medically necessary treatment. Needless to say, there are serious concerns about this ruling and how it could inflate costs for future workers’ compensation claims.

In the case, Jared Carnes injured his back at work. He was scheduled to have major lumbar surgery with Dr. Eldan Eichbaum. The Request for Authorization (RFA) included a new bed to “alleviate his pain and allow him to get rest” post surgery – specifically a $5,325 Sleep Number i8 bed. This request was denied in Utilization Review (UR), but the decision was untimely. As we saw in the Dubon II and Timothy Bodam cases, an untimely UR is defective, and in that instance the WCAB will determine if the requested treatment is medically necessary.

At bar, the parties stipulated that the UR was untimely and therefore defective. To most observers’ surprise and dismay, the WCAB ruled that the Sleep Number i8 bed, based on the recommendation by Dr. Eichbaum, was reasonable and medically necessary treatment.

However, the three judge panel ruled 2-1, with Commissioner Zalewski dissenting. She stated in her dissent that she believed that a Sleep Number i8 bed is not medical treatment an employer is obligated to provide. Specifically, Zaleweski stated that Dr. Eichbaum wrote that his patient had difficulty sleeping because his bed is “over 15 years old” and that he had “a very poor mattress.” But that does not establish that a Sleep Number i8 bed is reasonable and necessary medical treatment.

In a footnote, Zalewski drove the point home. She stated, “It may be that applicant has an old mattress and he would sleep better with a new mattress, just as other things are undoubtedly important to his recovery, like food, clothing and housing. However, that does not make defendant liable to provide all of those things as reasonable medical treatment.”

Since When Is a Bed Considered Medically Necessary Equipment?

UR’s purpose is to ensure that injured workers receive reasonable and necessary medical treatment. While there are standards for approving durable medical equipment (DME) to injured workers, the equipment generally consists of items such as wheelchairs, wheelchair ramps or lifts, canes, shower bars, potty chairs, and other equipment directly related to the injury. These items are often reasonable and necessary for the duration of an injured workers’ recovery. But since beds are a necessity for everyone, they really can’t be considered medical equipment.

If a Bed is Medical Equipment, is a Luxury Version Reasonable?

Moreover, the requesting physician on this case, Dr. Eichbaum, failed to provide substantial medical evidence that the Sleep Number bed in particular is medically necessary. According to Eichbaum, Carnes required a new bed because he has trouble sleeping and his current mattress is very old.

Carnes was scheduled to undergo back surgery. Even if we agreed that he needed a new mattress to support his back and aid in his recovery, would we have reason to believe that the $5,325 Sleep Number mattress was the only bed that could provide the support Carnes needed? Why, for example, wouldn’t a $300 Serta or $500 Simmons suffice? This is the kind of mattress that most of us sleep on every night. This question went unanswered by Dr. Eichbaum and by the majority opinion.

The Fact that an Injured Worker Wants a Piece of Equipment is Generally Irrelevant

Another concerning thing about this ruling is that, according to the dissenting opinion of Commissioner Zalewski, the only reason given for why Carnes required a Sleep Number bed is that he tried several other beds and liked the Sleep Number the most. But UR is not intended to award people what they want; it is intended to authorize medical treatment that people need in order to recover or get relief.

Certainly, if an injured worker has a legitimate concern about a piece of medical equipment, his treating physician can request another piece of equipment. But in this case the injured worker was awarded a luxury item that few can afford – just because he told his treating physician that he tried several beds, and that the Sleep Number i8 would be ideal. This must not become the standard for awarding medical equipment. The WCAB’s ruling sets a dangerous precedent for workers’ comp claims in California, threatening to inflate the size of any number of claims in the state by basing the standard on the injured worker’s desire.

Possible Repercussions of the Ruling: Paving the Way for Inflated Claims

If beds are suddenly “reasonable and necessary medical treatment,” what’s to stop lawyers from adding a “new bed” to every workers’ comp claim in California, adding $5,000 or more to each claim? This would cause insurance rates to balloon in California, the state that already has the highest rates in the U.S. It will be interesting to follow this case and see if the Court of Appeal overturns the decision. Ultimately, the Court of Appeal should follow Commissioner Zalewski’s dissenting opinion. Her logic is sound. An employer should not have a duty to provide a luxury item to an injured worker any more than they have a duty to provide food, shelter, and transportation. This is especially true with a lack of medical evidence to substantiate medical necessity of an item such as this Sleep Number bed.

Tom Swiatek

As Assistant Vice President of Regulatory Services and General Counsel, Tom Swiatek draws on his experience as an insurance attorney on both the general liability side, as well as on workers’ compensation matters. As a Workers’ Compensation Section Member, Tom is leading the discussion with respect to the regulatory challenges and opportunities facing the workers’ compensation system.