Taylor v. State of Delaware, 2024 WL 1209292 (Del. Super. Mar. 21, 2024)
Ms. Taylor injured her right wrist in 2016 while working as a teacher for the State. Her injury eventually developed into complex regional pain syndrome (CRPS) involving multiple extremities. From 2017 to 2021, the State paid for 23 ketamine infusion treatments to treat Ms. Taylor’s CRPS. The treatment was rendered by an out-of-state provider, Fort Washington Surgery Center. In 2019, the State contracted with a new bill-review company that paid substantially lower amounts than was previously paid for the same treatment. Ms. Taylor filed a petition that alleged these lower payments were insufficient and inconsistent with Delaware law. The Industrial Accident Board determined that the payments made by the State were correct under the Delaware Workers’ Compensation Act’s health care payment system and Fee Schedule. The Superior Court affirmed the decision.
The claimant appealed to the Delaware Supreme Court, arguing that the Board failed to correctly apply the Act and Fee Schedule regulations, as interpreted in the Superior Court opinion Delaware Veterans Home v. Dixon. Specifically, the claimant alleged that the Board failed to assess the adequacy of medical billing codes by referring to resources from the American Medical Association or the National Correct Coding Institute. The Supreme Court rejected this argument. The claimant bore the burden of proving whether the billing codes used by the provider for the ketamine infusion treatments were insufficient or inaccurate. The resources cited by the claimant were, indeed, referenced in the Fee Schedule administrative regulations, but no evidence was presented by the claimant at the Board hearing. It was neither the employer’s nor the Board’s responsibility to present that evidence. Therefore, there was no legal error. The court further advised that the Act’s Oversight Panel is the proper forum to determine whether specific billing codes provide reasonable compensation for particular treatment, which was a secondary argument advanced by the claimant. The decisions below were affirmed.
