Workforce Safety and Insurance did not abuse its discretion by denying a request for approval of daily opioid medication in excess of 90 Morphine Milligram Equivalents. The district court judgment affirming WSI's managed care binding dispute resolution decision is affirmed.
James R. Lowe, Appellant
v.
Workforce Safety and Insurance, Appellee
No. 20240189
Appeal from the District Court of McKenzie County, Northwest Judicial District,
the Honorable Daniel S. El-Dweek, Judge.
AFFIRMED.
Opinion of the Court by Tufte, Justice.
James R. Lowe, self-represented, Newark, Texas, appellant; submitted on brief.
Jacqueline S. Anderson, Special Assistant Attorney General, Fargo, North
Dakota, for appellee; submitted on brief.
Lowe v. WSI
No. 20240189
Tufte, Justice.
[¶1] James Lowe appeals from a district court judgment affirming a managed
care binding dispute resolution decision by Workforce Safety and Insurance
(“WSI”) relating to Lowe’s chronic opioid therapy coverage. On appeal, Lowe
argues WSI abused its discretion by denying his request for approval of
continued opioid medication in excess of 90 Morphine Milligram Equivalents
daily. We affirm the district court judgment affirming the managed care binding
dispute resolution decision by WSI.
I
[¶2] The WSI organization “shall establish a managed care program, including
utilization review and bill review, to effect the best medical solution for an
injured employee in a cost-effective manner upon a finding by the organization
that the employee suffered a compensable injury.” N.D.C.C. § 65-02-20. “If an
employee, employer, or allied health care professional disputes a managed care
decision, the employee, employer, or allied health care professional shall request
binding dispute resolution on the decision.” Id. “Dispute resolution under
[N.D.C.C. § 65-02-20] is not subject to chapter 28-32 or section 65-01-16.” Id. “A
dispute resolution decision under this section requested by an employee is
reviewable by a court only if medical treatment has been denied to the
employee.” N.D.C.C. § 65-02-20. “The dispute resolution decision may be
reversed only if the court finds an abuse of discretion in the dispute resolution
process.” Id.; see also Whedbee v. N.D. Workforce Safety & Ins. Fund,
.
[¶3] On November 22, 2021, Lowe was notified by WSI of a law that was passed
by the 2021 North Dakota Legislature, which would take effect July 1, 2022,
explaining: “Effective July 1, 2022, WSI will no longer cover a combination of
opioid and benzodiazepine drugs. A combination of all opioid medications
cannot go over 90 milligram morphine equivalent per day, and total duration of
a benzodiazepine therapy cannot go over 4 total weeks.” WSI further notified
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Lowe he must “[w]ork with [his] medical provider to reduce opioid and/or
benzodiazepine usage by July 1, 2022, to maintain coverage for these therapies.”
The notification also stated: “If there is a medical necessity for exceeding these
limitations, your medical provider will need to complete a Provider’s Request
for Medication Prior Authorization (M11) form and submit supporting
documentation for WSI to review.” Lowe’s medical provider, Balch
Interventional Pain & Wellness Center, was copied on the correspondence.
[¶4] Lowe was notified of the change in the law on November 22, 2021, and
again on April 1, 2022. The law was effective July 1, 2022. After Lowe’s provider
requested authorization for the dosage in excess of 90 MME, a full review was
conducted by WSI. The request was denied, citing several areas wherein the
provider’s treatment course did not align with guidelines governing long-term
assessment and management of opioid pain. The record does not show an
attempt to remedy those guideline delinquencies. WSI again reviewed Lowe’s
request before issuing its binding dispute resolution. WSI did not act arbitrarily,
unreasonably, or capriciously. WSI did not misinterpret or misapply the law. The
record does not show an abuse of discretion in the dispute resolution process.
See N.D.C.C. § 65-02-20.
[¶5] Section 65-05-40, N.D.C.C., permits WSI to depart from the established
limits “upon a showing of medical necessity.” Lowe does not cite a medical
necessity. The record does not show any support for the medical necessity of the
continued use in excess of 90 MME. Specifically, the record does not show an
attempt to reduce the high dosage nor does the record reconcile the success of
alternative treatments with a need to continue dosage in excess of 90 MME. The
binding dispute resolution is supported by the record. After reviewing the
record, we conclude WSI did not abuse its discretion by denying Lowe’s request
for approval of continued opioid medication in excess of 90 Morphine Milligram
Equivalents daily.
II
[¶6] We affirm the district court judgment affirming the managed care binding
dispute resolution decision by WSI.
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[¶7] Jon J. Jensen, C.J.
Daniel J. Crothers
Lisa Fair McEvers
Jerod E. Tufte
Douglas A. Bahr
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