What Is “Reasonable and Necessary” Treatment?

In an earlier post we briefly summarized the benefits to which a worker who suffers a work-related injury is entitled under Arizona’s workers’ compensation law. Among these, as in most states, are the “reasonable and necessary” costs of medical treatment. In this post, we discuss ways in which those terms have been interpreted.

What constitutes “reasonable and necessary” is determined in each state through some combination of statutory or regulatory definitions and case-by-case decisions by hearing officers, administrative appeal bodies, and the courts.

Although this means that what is considered reasonable and necessary varies widely from state to state, most common outpatient procedures and medications administered or prescribed by a licensed physician, along with inpatient or outpatient surgery and hospitalization, are included. Depending upon the nature of the injury, the costs of additional or alternative treatments, including physical and occupational therapy, may also be covered, as is the acquisition of many types of durable medical equipment, such as wheelchairs.

A workers’ compensation insurer’s payment obligations are of course not unlimited, however. Even when the insurer does not dispute the need for some treatment, medication or equipment, it may nevertheless argue that a less costly and equally effective alternative exists.

Here are a few examples of therapies, medications, and equipment ordered by treating physicians in Arizona and other states that have been disputed – with varying degrees of success – by insurers.

Special Equipment and Devices 

A motorized wheelchair may cost over $2,000, whereas a non-motorized counterpart will sell for a fraction of that amount. If the claimant is likely to need the chair for no more than a few months, the insurer will likely take the position that the non-motorized version is adequate. If the claimant is likely to be confined long term or even permanently, however, the motorized version may be considered a reasonable and necessary expense.

Home Equipment Purchases 

– A treating physician may prescribe the purchase of items such as specialized furniture to accommodate the claimant’s condition or exercise equipment or a hot tub for the claimant to use for therapy. The insurer is likely instead to approve rental furniture and physical and hydrotherapy sessions at a nearby outpatient treatment facility.

Medical Marijuana 

– Following a recent appeals court decision reversing a denial of reimbursement,  New Mexico now considers legally prescribed medical marijuana to be reimbursable if deemed reasonable and necessary to the claimant’s recovery. Although medical marijuana is legal in Arizona, it does not appear that the state Industrial Commission has as yet been asked to decide the question presented in the New Mexico case.

Sleep Number Bed 

– In a 2015 decision that sparked debate among workers’ compensation professionals nationwide, the California Workers Compensation Appeals Board affirmed an administrative judge’s decision ordering reimbursement to the claimant’s for his purchase of a $5,300 Sleep Number i8 mattress. A dissenting member of the Board contended that while a replacement mattress was reasonable and necessary, there was no medical basis on which to conclude that the more costly mattress would be superior to a traditional mattress in helping the claimant overcome his injury-related sleeplessness.