The Supreme Court of Washington on Thursday ruled that the state’s Department of Labor and Industries must re-evaluate its refusal to cover a man’s hip surgery, thus clarifying the state’s Health Technology and Assessment program and the Health Technology Clinical Committee’s job in determining whether a procedure is medically necessary.
Michael Murray suffered a hip injury while at work in August 2009. L&I allowed his claim and provided medical treatment, according to documents in Michael M. Murray v. State of Washington, Department of Labor and Industries, filed in Olympia, Washington.
Murray’s physician later asked L&I to authorize surgery regarding Mr. Murray’s hip condition, femoroacetabular impingement syndrome, a condition in which extra bone grows along one or both of the bones that form the hip joint. L&I denied payment for the FAI surgery because the Health Technology Clinical Committee disallowed coverage for that procedure. L&I had “not independently determined whether the FAI surgery is medically proper and necessary,” according to documents.
Meanwhile, the doctor performed the surgery on Mr. Murray without authorization from L&I and rehabilitated Mr. Murray’s hip injury, according to documents.
Mr. Murray subsequently appealed L&I’s decision denying payment for the surgery to the Board of Industrial Insurance Appeals, which affirmed L&I’s decision. He then appealed to the Superior Court, which affirmed the board. Mr. Murray followed up with an appeal to the Court of Appeals, which affirmed the Superior Court, holding that the state legislature constitutionally delegated its powers to the HTCC and “based on the plain language analysis of the statute,” an “HTCC noncoverage determination is a determination that the particular health technology is not medically necessary or proper in any case,” according to that ruling.
The state Supreme Court overturned the ruling Thursday, sending Mr. Murray’s case back to L&I for another hearing on the merits of the reimbursement claim. In accordance with case law, the Supreme Court referenced that “since such treatment can be approved in certain cases, it follows that the presumption that it is not medically necessary can be rebutted. This regulation requires the department to use a case-by-case analysis based on the definition of medically necessary found.”
“We hold that Murray is entitled to an opportunity to rebut the presumption that the controversial FAI surgery he received was not ‘proper and necessary’ under the circumstances of his case,” the ruling states.
“That is, Murray is entitled to an individual coverage decision by L&I, which is then subject to the appeal procedures… We reverse the Court of Appeals and remand Murray’s reimbursement claim to L&I for a hearing.”
The state Supreme Court also granted that L&I pay Mr. Murray’s attorney fees.
A spokesman for L&I could not be reached for comment Monday.