Judge orders Walmart to cover spinal fusion surgery

Walmart Inc. must cover the spinal fusion surgery a doctor in 2016 said would help a worker with chronic back pain after a slip and fall along with attorney fees following a litigated claim, an appeals court in Louisiana ruled Wednesday.

Ralph Stretzinger sipped on a wet floor in 2014, suffering compensable injuries his doctor classified as “serious” to his neck, back and lower extremities. His follow-up care included treatment with “multiple medical providers,” one of which deemed him a candidate for spinal fusion surgery, which Walmart and its insurer denied based on medical necessity and Louisiana workers compensation medical guidelines, according to documents in Ralph Stretzinger v. Claims Management Inc. and Wal-Mart, filed in the Court of Appeals of Louisiana, 5th Circuit in Gretna, Louisiana.

On request for review, the medical director of the state Office of Workers’ Compensation agreed with Bentonville, Arkansas-based Walmart but noted the “patient has criteria except for a psychosocial evaluation as required per the guidelines." Mr. Stretzinger submitted to the required psychological examination in February 2017 and was found to be a “good candidate for surgery,” documents state.

Later that year, Walmart denied the requested medical treatment as "not related to the on the job injury" and "not in accordance with the Medical Treatment Schedule” or state law, according to documents.

Mr. Stretzinger again sought review of this denial with the medical director, who in January 2018 rejected the application on the basis that disputes relating to compensability and/or causation – such as whether the requested medical treatment is "not related to the on the job injury"— are not addressed by the medical director. The medical director made no findings as to whether the requested spinal surgery fell within the medical treatment guidelines, according to documents.

Months later, Mr. Stretzinger filed a disputed claim for compensation with the Office of Workers’ Compensation. In its answer, Walmart denied that Mr. Stretzinger is entitled to the proposed lumbar fusion surgery because the treatment is contrary to state law and “unrelated to Mr. Stretzinger's work accident,” documents state.

A hearing on the claim was held in late 2018 and at the start of the hearing, Walmart “abandoned its argument that the proposed surgery was unrelated to Mr. Stretzinger's work accident and stipulated that there was no dispute in terms of compensability,” documents state. The parties then contested whether the surgery was medically necessary.

Earlier this year, a judge ruled in the worker’s favor and also ordered Walmart to pay $4,000 in penalties and attorney's fees and costs of $10,000.

On appeal, Walmart raised concerns over medical necessity, arguing the surgery fell outside of guidelines, and disputed the fines and attorney’s fees.  

The appeals court affirmed the order to pay for the surgery and attorney’s fees – adding an additional $2,000 for the appeal – yet remanded on the fines, writing that state law does not require employers to pay fines when treatment is in dispute, among other reasons, according to documents.

Walmart could not be reached for immediate comment.