Obtaining Schedule Award Benefits for a Claimant Following Denial of Authorization for Total Knee Replacement Surgery: M.M.

The claimant’s approved treating physician strongly recommended the claimant be authorized to undergo total knee replacement surgery. The request for authorization was denied. On this basis, Mr. Gest requested schedule award benefits for the claimant. The claimant’s physician advised that since the surgery was not authorized, the claimant’s condition had become permanent and stationary and reached a point of maximum medical improvement. The Claims Examiner denied the request for schedule award benefits, stating that the claimant was not authorized to undergo the surgery, but her condition was not considered to be permanent and stationary, since she needed the surgery.

Mr. Gest appealed this decision to the Branch of Hearings and Review. The Hearing Representative stated in the decision as follows:

In conclusion, the Office has not authorized the requested bilateral knee replacements for the claimant. In the absence of such procedures, her physician, Dr. Tauber, submitted impairment ratings of twenty-five per cent to each lower extremity based on the Fifth Edition of the A.M.A. Guides. Therefore, the claimant is entitled to claim her award, despite the possibility of a change in impairment in the future.