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Obtaining Authorizations – How the Process Works

August 2016

Featured Story

By Liana Dyson, Claims Specialist, Pinnacol Assurance

Pinnacol Assurance employees often field questions on how the authorization process works. There are three basic situations that require prior authorization:

  • Anything outside the guidelines
  • Anything exceeding the treatment guideline limitations
  • Anything in the guidelines that specifically requires preauthorization (for example, surgery or certain types of ancillary treatment)

The official wording reads: In admitted claims where treatment falls within the purview of a Colorado Division of Workers’ Compensation (DOWC) Medical Treatment Guideline, prior authorization for payment under Rule 16-9 is unnecessary unless the guideline specifies otherwise.

If additional treatment in excess of the original primary care physician’s prescription is recommended by the provider receiving the referral, the provider who receives the referral should not contact Pinnacol for prior authorization for payment. In accordance with Pinnacol’s existing gatekeeper model and the SelectNet Manual’s Participation Guidelines, the PCP and the provider can discuss the specific treatment goals, including functional gains and medical necessity of the additional treatment. If the PCP agrees with the additional treatment, then prior authorization for payment is required only if the treatment exceeds the limitations of the DOWC Treatment Guidelines.   

The authorization process at Pinnacol starts with a request from the provider. Pinnacol claims representatives review the request for relatedness and medical necessity. The authorization or denial will be made within seven business days from the receipt of a routine request. In the case of an emergent procedure, the treatment should be given and a retroactive authorization sought from Pinnacol. Lack of authorization should not delay treatment if it is an emergency. However, the authorization may be denied, and the patient may need to seek retroactive authorization through private insurance.

There are situations where utilization review or medical case management may be required. Requests outside of the guidelines and those for complicated surgeries will be reviewed. If there is a question of how much of the pathology is related to the current injury versus pre-existing condition, these cases will be evaluated. Requests for experimental or unproven procedures and equipment will also be reviewed. 

In cases being reviewed for compensability, an investigation will be done by the claims representative as quickly as possible. In each situation this may include, but not be limited to, contact with the policyholder, injured worker and any witnesses. Prior medical history and medical releases may also be requested. In other cases, an independent medical exam may be requested.  

To learn more about the authorization process and talk with Pinnacol experts, attend the Obtaining Authorizations session at Pinnacol’s Healthcare Conference on Sept. 29 in Denver or Oct. 7 in Grand Junction.   

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The Numbers Don’t Add Up for Amendment 69

August 2016

Corporate News

This November, Colorado residents will vote on Amendment 69, an initiative that would create a single-payer health care system called ColoradoCare. Pinnacol has many concerns about this proposal, primarily the devastating impact it would have on the state’s stable workers’ compensation system. But the effects of the plan will be felt far beyond workers’ comp, with a chilling effect on Colorado’s economy and competitiveness. 

According to a report by the nonpartisan Colorado Health Institute (CHI) released earlier this month, the new system “would nearly break even in its first year … but it would slide into ever-increasing deficits in future years unless taxes were increased.” That’s because, despite offering savings on administrative costs, the proposal does nothing to contain the decades-long trend of health care cost increases.

Put simply, ColoradoCare would not be able to sustain itself with the currently proposed 10 percent tax on payroll, retirement and investment income, a rate that would make Colorado the highest-taxed state in the nation. 

To cover its ever-increasing costs, ColoradoCare would have limited options: increase taxes, offer fewer health care benefits, increase deductibles or co-pays, or decrease payments to health care providers. All these options would hurt Coloradans. 

CHI’s report highlights the sandy financial foundation of Amendment 69, which puts the future of Colorado’s thriving economy on the line. 

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Imaging in Work-Related Back Pain

August 2016

Clinical Corner

By Chris Bellmar, DPT Regional Director, Colorado Outpatient and Physical Therapy 

Most guidelines on management of low back indicate a lack of need for imaging except in the case of significant trauma or neurological deficit or red flags indicative of back-related tumor, cauda equina syndrome, back-related infection, compression fracture or abdominal aneurysm.1 The American College of Occupational and Environmental Medicine does not recommend MRI for patients with radiculopathy unless, at four to six weeks, symptoms are “severe and not trending towards improvement and both the patient and the surgeon are willing to consider prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression.” Following four to six weeks from onset, ACOEM recommends MRI for subacute or chronic radicular pain syndromes when the symptoms are not trending towards improvement if both the patient and surgeon are considering prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression. In cases where an epidural glucocorticosteroid injection is being considered for temporary relief of acute or subacute radiculopathy, MRI at three to four weeks (before the epidural steroid injection) may be reasonable. In cases where conservative treatment (including NSAIDs, aerobic exercise, other exercise, and considerations for manipulation and acupuncture) over the course of three months have failed, MRI is recommended as an option for the evaluation of select chronic LBP patients in order to rule out concurrent pathology unrelated to the injury.2

The rationale behind the use of caution when considering imaging in occupational-related low-back is related to the prevalence of significant findings in the absence of pain, which may complicate the clinical picture in those with current symptoms. Studies investigating MRI results of individuals without back pain have found significant anatomic changes, including 91 percent having disk degeneration, 56 percent having loss of disk height, 64 percent having disk bulges, 32 percent having disk protrusions and 38 percent having annular tears.3 When MRIs are performed, it is important that results are communicated to patients using language that is easy to interpret and will not induce fear. Many existing medical terms included in MRI reports have been shown to have different meanings to patients than intended.4 One study demonstrated value in the inclusion of the following statement on MRI results: “The following findings are so common in people without low-back pain that while we report their presence they must be interpreted with caution and in context of the clinical situation.” This simple statement included by radiologist on the MRI report was associated with decreased prescriptions of narcotic medications from primary care physicians.3 Performance of MRIs in the management of low-back pain has been linked to worse health outcomes, increased likelihood of disability and longer disability duration.5 Workers who present with low-back pain that have an early MRI, in the absence of key indicators for significant pathology, have a higher risk of disability and surgery, irrespective of the severity of the MRI findings.6,7

Using MRI and other imaging in the absence of significant clinical findings in search of the problem is associated with poorer outcomes and higher costs. MRI and all imaging should be used judiciously and for specific indications and to confirm a clinical picture and execute a predetermined plan. 

References 

1. Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. (2012) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 42(4): A1-A57. 

2. Low back disorders. In: Hegmann KT, editor(s). Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011: 333-796. 

3. McCullough, BJ, Johnson GR, Martin BI, Jarvik JG. (2012) Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology. 2012;262(3): 941-946. 

4. Sloan TJ, Walsh DA. (2010) Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine (Phila Pa 1976). 2010 Oct 1;35(21): E1120-E1125. 

5. Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine (Phila Pa 1976). 2012;37(18): 1617-1627. 

6. Webster BS, Cifuentes M. (2010) Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9): 900-907. 

7. Webster BS, Cifuentes M. (2010) Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9): 900-907. 

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The Biopsychosocial Aspects of Injury Evaluation and Treatment

August 2016

Clinical Corner

By J. Mark Disorbio, Ed.D.

There is a growing body of evidence that disease causation and outcomes are linked to the interaction of multiple biological, psychological and social factors. The combination of genetics, biochemistry, mood, personality, behavior, culture, and family, medical and social factors can be used to identify risks that compromise the ability of a patient to benefit from medical treatment.

One of the most studied topics in the biopsychosocial model is the assessment and treatment of pain conditions. Given the complex nature of pain, it is crucial to determine the medical aspects of the injury and the psychosocial contributions.

With the assistance of 26 subject matter experts, the American College of Occupational and Environmental Medicine developed evidence-based treatment guidelines. The published criteria for a psychological referral include:

  • A suspicion of psychological dysfunction
  • A history of major psychiatric disorder
  • Catastrophic injury
  • Evidence of cognitive impairment
  • Prescription and/or drug problems
  • Delayed recovery and noncompliance or adherence  

The complexity of underlying conditions and the vulnerability of an injured worker to multiple risk factors can make the physician’s evaluation and treatment of injured workers a challenging task. Psychosocial complications impact the patient’s ability to adhere to treatment and can intensify the perception and report of symptoms. What patients say and how they behave may not align with the objective test results observed by the clinician. 

Incorporating psychological assessments into the treatment plan can assist the physician and care team to identify situations and settings that may be impacted by biopsychosocial aspects. Physician offices, acute physical therapy, work hardening programs, chronic pain programs and vocational rehabilitation settings, may observe behaviors and underlying conditions that delay recovery. Although the decision to proceed with a particular course of treatment is a medical one, the psychological aspects of the case can improve the case outcome.  

The objective indications for intervention for psychological treatment, medication management programs, surgery and other invasive treatments is best performed collaboratively by physicians and psychologists. Risk scores from psychological assessments can be helpful as an objective means of quantifying the risk factors present. Because some medical procedures and treatment can be irreversible and have significant risks or side effects, elevated risk scores might suggest more cautious approaches to treatment.  

I am presenting at Pinnacol Assurance's upcoming Healthcare Conference and will focus on identifying risk factors to help providers making medical decisions.  

The presentation will cover questions to ask patients to assess: 

  • Presurgical readiness
  • Opioid medication management
  • Quality of life issues and overall rehabilitation risk

I will discuss the concepts of catastrophizing, kinesiophobia and craving as they apply to addiction. Please join me Sept. 29 in Denver or Oct. 7 in Grand Junction.

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Pinnacol Healthcare Conference Expands Agenda, Broadens Participation

July 2016

Featured Story

The 2016 Pinnacol Healthcare Conference offers tracks for clinicians and practice staff and welcomes out-of-network providers.

With a new name, a new format and new content, our annual provider event — renamed the Pinnacol Healthcare Conference — this year will offer new and greatly expanded continuing education not just in Denver, but in Grand Junction as well, and promises to attract a record number of attendees.

The Denver event on Sept. 29 will welcome as many as 250 providers; the Grand Junction conference expects about 100 attendees. 

Broadened participation, distinct tracks for clinicians and practice staffs

This year Pinnacol is inviting out-of-network providers to the accredited conference events. In past years, attendance was limited to Pinnacol’s proprietary SelectNet network.

“Out-of-network physicians and facilities treat our policyholders’ injured workers too,” noted Network Educator Laura Palmer, who plans and executes the Pinnacol Healthcare Conference and other educational programs for our healthcare stakeholders. “Pinnacol is making educational opportunities available to SelectNet and non-SelectNet providers to enable the most coordinated, highest-quality care and best outcomes for injured workers.”

The excitement this year is also due to the offering of billing and administrative topics as a separate, distinct track. This will allow practice management staffs — perhaps 40 percent of attendees — to attend sessions most helpful to them, while clinicians benefit from sessions focused on patient treatment.

As in previous years, the 2016 conference will offer insightful panels on the latest clinical developments. But there will also be sessions on communications and relationship-building. “How to Coach Your Patient to Show Up in the Healing Process” will be one keynote address. Another is titled “Managing Relationships — Dealing With Difficult People.”

Provider feedback, input drive accredited conference content

“Surveys and focus groups told us that providers can get continuing education events elsewhere that offer strictly clinical information,” Palmer said. “What providers want is guidance on how to manage varying personalities and challenging interactions. They want continuing education on how to involve patients in shared decision-making, as well as how to optimize relationships with employers, attorneys and practice staff. Uniquely, Pinnacol will provide accredited guidance on these critically important soft skills.”

“Kudos to Laura for digging into feedback from prior-year events,” said Director of Provider Network Management Bonnie-Lyn Cahoon, Palmer’s manager. “The buzz about the Pinnacol Healthcare Conference is due in large part to Laura’s efforts.” 

Cahoon said Palmer has pored over evaluations, involved co-workers, consulted with SelectNet clinicians and administrators, and coordinated closely with the Colorado Medical Society. Palmer has used this collective input from the provider community to determine the agenda of the 2016 Pinnacol Healthcare Conference. 

“Hired earlier this year, Laura brings 12 years of occupational medicine experience, as well as 14 years of physician education and practice management experience,” Cahoon added. “I’m confident this will be reflected in the quality of this fall’s Denver and Grand Junction events.” 

Register now for the conference or contact your provider relations specialist for details.

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Understanding Your Biggest Challenges

June 2016

Corporate News

Several weeks ago, we asked you to respond to a survey to help Pinnacol assess the needs of the clinical provider and administrative community we value so highly.  Through this research, we have affirmed our positive working relationship with our provider community and gathered ideas for providing increased value.

The goal of this research was to inform strategies to expand communication, content, resources, tools and education for providers and understand the specific and unique needs of subsets of the provider community. 

Findings

Overall impressions of Pinnacol were very positive, and respondents appreciated that Pinnacol solicits providers’ feedback and focuses on continuous improvement. 

One provider said, “From a physician’s standpoint, they’re probably the easiest carrier I work with — especially their accessibility and willingness to talk to me. And aside from the financial side, they’re the easiest one as far as billing is concerned. But I think it’s the personal relationships that really make it unique for me as a physician.” 

Seventy-six percent of respondents said they valued interactions with their Pinnacol Provider Relations Specialists, and 75 percent said additional education and resources would further improve their satisfaction with Pinnacol. 

Top challenges

Respondents were asked to rate challenges they encountered when handling all workers’ compensation claims:  

  1. Understanding the DOWC rules, fee schedule and treatment guidelines
  2. Employer relations
  3. Navigating Pinnacol’s online provider portal
  4. Injured worker relations
  5. Billing and coding 

When working specifically with Pinnacol, respondents noted these tasks as challenging:  

  1. Managing claims denials
  2. Understanding the approval process
  3. Meeting credentialing requirements for accreditation
  4. Utilizing Pinnacol’s online provider portal 

Researchers also discovered that clinic administrators’ and clinicians’ needs were distinct. Administrative professionals said they value education and resources related to claims processing and communication, and clinicians value information about best practices for treating workers’ compensation patients and managing relationships with injured workers and employers. Administrators also said they prefer brief, more frequent email updates from Pinnacol, while clinical providers preferred less frequent and more specialty-specific content. 

Education topics were ranked by interest:

  1. How to bill and code effectively
  2. Understanding the DOWC rules, regulations and treatment guidelines
  3. Clinical best practices
  4. Advanced workers’ comp tutorials
  5. Basic workers’ comp tutorials
  6. How to network with other providers and build referrals 

Outcomes 

Pinnacol teams are hard at work identifying and enhancing the education, resources and tools most valued by the provider community.  

Pinnacol recently hired a full-time Network Educator, Laura Palmer, who brings experience in provider relations, education and medical practice administration. Her background includes 12 years in occupational medicine practice administration, 10 years of physician consulting with the Texas Medical Association and, most recently, as the Director of Professional Development for the Medical Group Management Association.  

Within the next several months, Pinnacol will be rolling out: 

  1. Enhanced interaction with Provider Relations Specialists. Focus group participants liked Pinnacol’s expanded approach to PRS, and providers will have access to more resources and customized information and education through their designated specialists. Staff will visit clinics more frequently, and the information they present will be customized to meet specific clinic needs, such as coding, documentation or billing.    
  2. Improved timeliness of communication and access to information  
  3. Expanded educational offerings and formats including in-person and online education
  4. More online resources, tools, information and content 

“With input from the provider community, we can provide new and ongoing training for billing, administrative and clinical staff to improve processes and understanding. Through enhanced relationships and closer communication, providers can expect targeted resources and education from Pinnacol. We would love to hear your suggestions for improvement,” said Palmer.  

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Endoscopic Carpal Tunnel Release

June 2016

Clinical Corner

Submitted by Steven M. Topper, MD

The debate in the scientific literature between open and endoscopic carpal tunnel release (ECTR) through the 1990s and into the early part of the 21st century was voluminous. In the end, we were left with no definitive scientific proof favoring one procedure over the other. Consequently, both are still done today. While the controversy has died down, questions still remain. The Academy of Orthopedic Surgeons Work Group, which created clinical and diagnosis guidelines for carpal tunnel release, expressed in their 179-page report what is generally accepted as the conventional wisdom. They concluded that ECTR was favored for outcome measures of less pain, greater pinch strength and fewer wound complications at 12 weeks. Open carpal tunnel release was favored for fewer reversible nerve issues (neuropraxia is slightly less likely with open carpal tunnel release). There were no differences for functional status and symptom severity at one year, including complications or infections.1 In other words, both procedures are equally safe and effective, and there is a quicker recovery with the endoscopic approach in the first three months which has obvious implications in the workers’ comp setting. Perhaps societal issues such as cost-effectiveness and quality of life will drive us to seek more definitive answers, such as happened with laparoscopic cholecystectomy. Until that time, we are left with randomized controlled trials and meta-analyses that generally have insufficient power and inconsistent outcome measures, making it hard to draw conclusions. 

Fortunately, division of the transverse carpal ligament is an effective way to treat carpal tunnel syndrome. The application of minimally invasive (endoscopic) techniques to the most commonly performed orthopaedic procedure, back in the 1980’s, made sense. The hope was that it would decrease the morbidity of the procedure and yield a quicker recovery. In so doing it may also create a societal cost savings, in light of the number of working “young” people that have carpal tunnel surgery. Though there is no definitive scientific proof that this has been accomplished, there is also no proof that it hasn’t. Early on, there were concerns about the safety of ECTR because the technical aspects of the procedure required a relatively new skill set called triangulation. Triangulation is used in all arthroscopic and endoscopic procedures today and is a universal skill set among orthopedic, plastic and general surgeons. 

From a practical point of view, in the work comp setting, recovery time matters. The three primary factors in determining return to work recommendations include risk, capacity, and tolerance. Risk involves the likelihood of exacerbation, recurrence, or re-injury. Capacity is an individual’s actual functional ability to perform required tasks, and tolerance is the individual’s perceived ability based on pain behavior and willingness to perform duties. We advise our patients who have had an ECTR to continue with activities as tolerated without requiring medically necessary activity restrictions. Given that there is relatively little tissue damage as result of the ECTR technique, the risk of re-injury or exacerbation of problems is small. Capacity to perform activities is limited only secondary to postsurgical pain at the incision site and any preexisting deficits such as weakness, numbness and tingling, or pain that take time to resolve after the carpal tunnel has been decompressed.2

As there is little risk of re-injury following the minimally invasive ECTR technique, sedentary type workers are advised to return to work on postoperative day one or two and manual laborers on postoperative day 5-7. Official Disability Guidelines recommend 21 days as the optimum return-to-work best practice for people who perform medium level work (exerting up to 50 pounds of force occasionally, and/or up to 25 pounds of force frequently, and/or up to 10 pounds of forces constantly to move objects.) The recommended optimum ranges vary from 7 days for sedentary work to 48 days for very heavy work.3

In the first quarter of 2016, The U.S. Department of Labor’s Bureau of Labor Statistics has estimated the cost of lost productivity at $830 per week based on the median weekly earnings (not seasonally adjusted) of full-time wage and salary workers.4 The difference in lost work productivity due to differences in return to work between ECTR and open surgical treatment for carpal tunnel syndrome is estimated to be $2,656 per patient.   (Estimated as 21 days – 5 days = 16 days x $166/day = $2,665 using medians and averages). While this is a rough estimate based on accepted guidelines, it does bring into focus a concept that is particularly relevant in the workers’ comp setting.

Steven M. Topper, MD, President

Colorado Hand Center

2925 Professional Place 

Colorado Springs, CO 80904

References

1. CTS Guideline 2016 - Work Group Members. "CTS Treatment Guideline." AAOS. American Academy of Orthopaedic Surgeons. 18 Apr. 2013.  http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp. (Requires member login), Accessed 6/16/16

2. http://www.mdguidelines.com/carpal-tunnel-syndrome  Accessed 6/16/16

3. http://www.mdguidelines.com/search/medical-disability-advisor Accessed 6/16/16

4. http://www.bls.gov/news.release/wkyeng.nr0.htm  Released April 19, 2016, Accessed 6/16/16

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Amendment 69 Would Demolish Colorado’s Stable Workers’ Comp System

June 2016

Workers' Comp Coordination

Colorado’s workers’ compensation system is one of the best in the nation, effectively balancing the needs of labor and business. The stability and financial security of the system is a boon to the state’s economy, helping retain business and lure new employers. But that will change if Amendment 69, or ColoradoCare, is approved by voters in November. Read the full story

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Colorado Supreme Court Clarifies Standard for Firefighter Cancer Claims

June 2016

Workers' Comp Coordination

By Harvey Flewelling, Associate General Counsel, Pinnacol Assurance

Policyholders expect us to understand what’s happening in their businesses and their industries. One way Pinnacol’s Public Entity Sector Center of Excellence is working to meet this obligation is to find and share information that may impact the industries we work with. Recently, Colorado’s Supreme Court issued decisions on three workers’ compensation cases involving firefighter cancer. Although these decisions won’t change the way Pinnacol handles claims, we want to ensure that you, as our provider partners, are informed. 

The Colorado Supreme Court recently issued decisions in three workers’ compensation cases involving firefighter cancer. These decisions clear up confusion around when cancers suffered by firefighters can be presumed to have been caused by their occupation. This article explores two of these decisions that best illustrate the issues being disputed and explains the implications of these decisions for Pinnacol’s policyholders and their injured workers. 

Background

In 2007, the Colorado General Assembly passed a law to make it easier for firefighters who have cancer to receive workers’ compensation benefits. That law creates a presumption that certain types of cancer result from a firefighter’s employment, as long as the injured worker has worked as a firefighter for at least five years and a pre-employment physical examination did not reveal such cancer. In other words, as long as these tests are met, it is legally presumed that workers’ compensation insurance will cover a firefighter’s cancer. However, the law also created an opportunity to overcome that presumption if the employer shows by a preponderance of the medical evidence that the cancer did not occur on the job.

Since the law was passed, it has been interpreted inconsistently by the courts. That’s created confusion about whether and to what extent the presumption can, in fact, be overcome. With its decisions in City of Littleton v. Industrial Claim Appeals Office, and in Industrial Claim Appeals Office v. Town of Castle Rock, the Colorado Supreme Court has now cleared up that confusion.

Overview of the issues

In City of Littleton, the injured firefighter was diagnosed with brain cancer. He met the test for the presumption that his cancer was compensable. However, the administrative law judge (ALJ) denied compensability after concluding that the employer had proven that his cancer was not related to his employment. The worker appealed, and a panel of the Court of Appeals reversed the ALJ’s decision on the grounds that the employer did not disprove the specific causation of the worker’s cancer.

The Supreme Court reversed the judgment of the Court of Appeals. The court held that an employer can meet its burden to overcome the presumption by establishing the absence of either general or specific causation — in other words, a fairly broad interpretation of the law.

The Town of Castle Rock case involved a worker who had worked as a firefighter, engineer and paramedic. During his off hours, he worked in construction — and sometimes outdoors — framing and building decks. He was diagnosed with malignant melanoma on his right outer calf. He underwent three surgeries to remove the growth and filed for workers’ comp coverage. The employer sought to deny the claim by presenting expert testimony that the worker’s various other exposures and risk factors placed him at far greater risk of developing melanoma than his activities as a firefighter. An ALJ disagreed, saying that the statute required proof that the injured worker’s cancer came from a specific cause not occurring on the job and requiring the employer to cover the claim. The employer appealed, and a different panel of the Court of Appeals sided with the employer, saying that an employer may overcome the presumption of compensability with specific evidence demonstrating that a particular firefighter’s cancer probably was caused by a source outside his firefighting work.

In this case, the Supreme Court affirmed the decision of the Court of Appeals, holding that the employer does not need to pay the claim if a preponderance of the medical evidence establishes that the firefighter’s particular risk factors make it more probable that the cancer arose from a source outside the workplace.

Implications

These decisions provide clearer guidelines for determining when it is appropriate to award workers’ compensation benefits in a firefighter cancer claim. While the presumption that a firefighter’s cancer is caused by on-the-job exposure remains in place, these decisions clarify the grounds on which an employer or insurance carrier can overcome that presumption and deny the claim. However, it’s important to understand that the presumption is not easy to overcome.

As we always do, Pinnacol will continue to investigate the merits of all claims individually. Based on the evidence obtained in our investigation and the applicable legal guidelines, we will then determine the position we will take on each claim on a case-by-case basis.

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