Casillas vs. the County of San Luis Obispo (2005) 33 CWCR 217 (Opinion and Order Granting Reconsideration and Decision after Reconsideration)

In Casillas, the patient (who suffered an industrial injury in 2000) received a stipulated award for future medical care from the WCAB in 2002 and used this award to procure chiropractic treatment for flare-ups (exacerbations) of her chronic pain. It was noted that over the years the patient had procured over 100 chiropractic treatments, which the insurer paid for. In 2004 (after ACOEM was presumed correct on the scope of medical treatment), the insurer cut-off the patient’s chiropractic care after a UR doctor opined that said care was not ACOEM compliant.

Despite a favorable QME report that used the Mercy Guidelines and ACOEM itself to support chiropractic care for acute exacerbations of a chronic condition, the insurer won the first battle as the WCJ sided with the insurer and denied chiropractic care based on ACOEM.

The decision was appealed upward to the WCAB where a panel of three commissioners was appointed to reconsider the decision. Commissioners Brass, Caplane, and O’Brien unanimously agreed to over-turn the WCJ opinion and ordered the insurer to pay for the chiropractic care. In relevant part, the commissioners stated:

“In short, we do not find the ACOEM Guidelines to specifically preclude continuing chiropractic carefor acute exacerbations of the applicant’s [the injured worker] symptoms. As such, no presumption is clearly established pursuant to [labor code] section 4604.5(c). But even if a presumption is said to exist, arguendo [argumentatively], we find in this case that the presumption would be rebutted by the reasoned opinion of the examining QME, the Mercy Guidelines, and the applicants experience in obtaining pain relief from acute exacerbations of her symptoms through the use of chiropractic care,” and “we will specify that future chiropractic care is to be provided when reasonably necessary to treat acute exacerbations of the applicant’s [the injured worker] symptoms.”

This was a wonderful decision, for it found that chiropractic care for acute exacerbations of a chronic condition can be treated with chiropractic manipulation and physiotherapy even if said care was not specifically mentioned in the award. The simple fact that the insurer had paid for it for years was enough to prove it was an insurance-accepted treatment intervention and using ACOEM to cut it off was wrong.