Opinion
¶1 Elizabeth A. Hoffman suffered a work-related injury that resulted in multiple surgeries and chronic pain. Her doctors prescribed her opioids and other medications. For many years, Delta Air Lines (Delta) and its insurance carrier, Hartford Insurance Company (Hartford; collectively, Respondents), paid for these medications. But after a doctor hired by Hartford performed a medical examination of Hoffman (an insurance “defense exam”) and recommended weaning with professional assistance, Respondents stopped paying for Hoffmans medications altogether and made no provision for weaning. Hoffman initiated a formal adjudicative proceeding against Respondents through the Utah Labor Commission (the Commission), and a medical panel opined that a level of opioid use lower than Hoffman had previously taken was historically necessary. Regarding future expenses, the panel indicated that Hoffman should undergo a formal weaning program to stop using opioids or else reduce her opioid use to a certain lower level.
¶2 An administrative law judge (ALJ) ordered that Respondents reimburse Hoffman for past expenses and follow the panels recommendations in providing a weaning program and covering the cost of the panels recommended lower opioid dosage if complete weaning was unsuccessful. Upon review, the Appeals Board of the Utah Labor Commission (the Board) interpreted the ALJs decision as covering the lower opioid dosage in the future without waiting for a weaning opportunity to trigger the reduced coverage, though it indicated that Respondents would be liable for the costs of a weaning program if Hoffman elected to participate in one. It also modified the order as to past expenses to cover only the dosages of opioids the panel had indicated were “necessary.” Hoffman now seeks judicial review of the Boards decision. We conclude that the Boards decision concerning the compensability of Hoffmans past and future expenses for medications is supported by the medical panels report and is therefore supported by substantial evidence. Accordingly, we decline to disturb its decision.
BACKGROUND
¶3 Hoffman sustained a work-related traumatic back injury in 1986 while working for Western Airlines, which later merged with Delta. For some thirty years, Hartford paid for Hoffmans industrial medical expenses and prescription medications. During that time, Hoffman underwent five back surgeries. After the last surgery in 2002, she had to stop working due to debilitating chronic back pain and pain in her right leg. Her physicians prescribed opioid pain medication to treat her pain, and she has taken these without cessation—though in varying amounts—since 2002. Her doctors also prescribed benzodiazepines, to treat the anxiety that Hoffman developed after the injury, and Soma, a muscle relaxant.
¶4 In 2006, the parties entered into a stipulated settlement wherein Hartford agreed “to continue paying reasonable medical expenses related to the accepted injuries.”
¶5 In January 2016, Hartford required Hoffman to undergo a defense exam with Dr. Deborah Mattingly. In short, Dr. Mattingly recommended that Hoffman be weaned from her medications under the supervision of a specialist. Soon thereafter, Hartford stopped paying Hoffmans medical and prescription expenses. Initially, Hoffmans private medical insurance paid for her medications, but when it too stopped, she began paying for them out of pocket.
¶6 Hoffman initiated a formal adjudicative proceeding against Respondents. The ALJ first assigned to the case, Judge Colleen Trayner, identified that the “only issues before the Court [were] necessary medical care from 2016 to the present and recommended medical care to treat [Hoffmans] industrial ․ condition.” Utah law dictates that an injured employees “employer or the [employers] insurance carrier shall pay reasonable sums for medical, nurse, and hospital services [and] for medicines ․ necessary to treat the injured employee.” Utah Code § 34A-2-418(1).
Judge Trayners Findings
¶7 Judge Trayner entered the following findings of fact:
On January 12, 2016, [Hoffman] underwent [a defense exam] with Dr. Mattingly. Dr. Mattingly opined that the only recommended treatment is to wean [Hoffman] from her opioids, benzodiazepines[,] and Soma. Dr. Mattingly opined that [Hoffman] requires a weaning from the opiates under the supervision of an addiction or pain specialist. This should not take more than six months. Dr. Mattingly also recommends a regular exercise program.
On March 29, 2016, Catherine Harmston, FNP, filled out a Summary of Medical Evidence. ․ Catherine Harmston opined that [Hoffmans] lumbar spine surgeries and opioid analgesics were necessary to treat [Hoffmans] 1986 industrial injuries. Catherine Harmston recommends physical therapy, consult with Dr. Nelson[,] and monthly medication.
On January 15, 2018, Dr. Stoddard filled out a Summary of Medical Evidence. Dr. Stoddard opined that [Hoffmans] opioid treatment was necessary to treat her 1986 industrial injuries. Dr. Stoddard recommends ongoing opioid treatment.
On January 29, 2018, Dr. Stoddard prescribed [Hoffman] a [Bowflex] machine, therapeutic hot tub[,] and housecleaning services every other week as a result of [Hoffmans] chronic back pain.
[Hoffman] underwent [a defense exam] with Dr. Jiricko on October 9, 2018. On December 14, 2018, Dr. Jiricko provided an addendum. Dr. Jiricko opined that he does not recommend a spinal cord stimulator or surgical intervention. Dr. Jiricko recommends weaning from the opioid medication. Dr. Jiricko notes that [Hoffman] requires a formal inpatient detoxification and/or a 4-week [structured intensive multidisciplinary program] ․ [Hoffman] requires a consultation with an addiction specialist or psychiatrist. Dr. Jiricko recommends a robust cognitive behavioral therapy training ․ and psychiatric evaluation for anxiety and medication management. Also, 10 to 12 sessions of physical therapy for [Hoffmans] right leg.
[Hoffman was] treated [by] Dr. Anden from November 1, 2018[,] through January 9, 2019․ Dr. Andens last medical care recommendation [was] to continue [the] same medications [and] independent home/gym exercise program[,] which includes walking, back stretches, core strengthening, and weight management. ․
(Internal citations omitted.)
¶8 Judge Trayner then concluded that “[t]here is a dispute among physicians regarding medical care after 2016 and recommended medical care to treat [Hoffmans] back condition.” Accordingly, she ordered “that the issues of medical and recommended medical care shall be referred to a medical panel for consideration.” See Utah Admin. Code R602-2-2(A) (“A panel will be utilized by the Administrative Law Judge where one or more significant medical issues may be involved.”).
The Medical Panels Report
¶9 The medical panels report, issued in July 2019, stated the following regarding past medical care:
Q: Please past medical care since 2016 been necessary to treat [Hoffmans] 1986 industrial back injury?[1]
A: The term “necessary” is ․ difficult to answer[,] especially in the setting of chronic pain. It is not considered medically necessary for her to continue with her opioids, benzodiazepine[,] and Soma because without those medications she would not die[,] and in reality, the use of these medications greatly increases her risk of death. However, her pain and anxiety would increase. From 2002–2016, she used excessive amounts of opioids at 440 mg of oxycodone[,] and to take away all the opioids quickly would be inhumane[,] and weaning would be mentally and physically challenging. We have had a difficult time deciding what is considered “necessary” in trying to balance humane treatment given her 14 years of continuous excessive opioid use with current medical standards for chronic pain and the risks and benefits of the opioids, benzodiazepine[,] and Soma.
We have decided that [Hoffman] “needed” the 120 mg of OxyContin (extended release oxycodone) a day. This amount is still over what is recommended by CDC and ACOEM guidelines for treatment of chronic pain[,] but it is improved from the 270 mg of oxycodone she is currently using.
We believe the benzodiazepine and Soma are clearly not medically necessary and are not indicated to treat chronic pain. The oxycodone 30 mg 5X/day is excessive and not medically indicated. There is no objective or subjective evidence that these medications ever improved her pain score or improved her function. In fact, her pain score and function are unchanged from the 440 mg of daily oxycodone use compared to the 270 mg of daily oxycodone she currently uses.
¶10 The medical panel said the following regarding future medical care:
Q: What medical care, if any, is recommended to treat [Hoffmans] 1986 industrial back medical condition, including but not limited to medications, spinal cord stimulator, [Bowflex] machine, housecleaning and therapeutic hot tub?
A: We believe that Dr. Jirickos plan is the most ideal. However, [Hoffman] has both psychologic and physical dependence o[n] the opioids (this is different [from] an opioid use disorder or opioid addiction)[,] and she is very anxious about not taking her medications. She is not psychologically ready to stop taking opioids[,] and having her go to treatment for the opioid dependence would not be successful until she wants to get off opioids. If she is unwilling to wean off her opioids, these are our recommendations:
1. Wean down to 180 mg of morphine equivalent dose a day (which is 90–120 mg oxycodone per day depending on [the] conversion ratio chosen). This can be a variation of OxyContin only, oxycodone only[,] or a combination of OxyContin and oxycodone.
Or
2. Switch to Buprenorphine 16 mg or less a day.
Regardless of which path she and her physician decide, she needs to stop using the benzodiazepine and Soma along with her opioid. There are better medications to treat her anxiety and sleep disorder with less risk profile. She would benefit from a [p]sychiatry evaluation to treat her anxiety from the chronic pain and [a] [s]leep specialist evaluation to treat her sleep disorder from chronic pain.
We do not believe she would benefit from the spinal cord stimulator to improve function or reduce medication. ․
We do not believe a [Bowflex] machine is medically indicated. Exercise is indicated and recommended, but virtually all forms of exercise are helpful (walking, swimming, core strength, yoga, etc.), but a specific brand name device is not needed.
We do not believe she would benefit from a hot tub. There is no scientific evidence to suggest hot tubs improve function or help chronic low back pain.
We do not believe housekeeping is medically necessary for her low back pain. She currently chooses to employ housekeeping services, but her current yard and animal care have similar physical requirements. Having housekeeping has not improved her function[,] nor has it allowed her to reduce her opioid use.
¶11 Hoffman filed a response containing multiple objections to the medical panels report. Respondents filed a response in support of the medical panels report. Meanwhile, the case was transferred to another ALJ, Judge Steven J. Rammell.
Judge Rammells Order
¶12 Judge Rammell issued findings of fact, conclusions of law, and an order in October 2019, wherein he found “that the [medical panel report] is the product of thorough, collegial, and impartial review, both of the entire medical record and of [Hoffman] herself,” and that the medical panel was “qualified to opine on [Hoffmans] historical and future medical treatment.” Accordingly, Judge Rammell “adopt[ed] and admit[ted] into evidence the [m]edical [p]anel [r]eport and conclude[d] that the panels findings [were] reliable and its treatment recommendations appropriate.”
¶13 Regarding future expenses, Judge Rammell ruled that Respondents are “obligated to pay for the expenses associated with the recommended future treatment” according to “the medical panels recommendations, both as they mirror those of Dr. Jiricko and the two proposed alternative options should [Hoffman] prove unwilling or unable to wean off her opioids.”
¶14 On the topic of past expenses, Judge Rammell grappled with the “rather unique issue” of “whether a carrier is obligated to pay for past medical expenses that have since been found unnecessary” based on the “medical panels conclusions that the benzodiazepine, Soma, and the previous dosages of opioids were not medically necessary.” On this question, Judge Rammell stated that “the appropriate course and timeframe for treatment of a petitioners industrial injuries may be determined by the petitioners treating physicians, but a respondents liability for such treatment does not extend beyond the care recommended in an adopted medical panel report.” However, Judge Rammell determined that “[Hoffman] properly relied on her treating physicians recommendations at the time” and “[a] medical panels later conclusions of excessive dosage should not be retroactively applied to punish [Hoffman] for following her physicians advice prior to the panels involvement.”
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¶15 Judge Rammell then reached the following conclusions:
Here, a preponderance of the evidence demonstrates that when [Hoffman] began taking this combination of medications for which she now seeks reimbursement, “․ high dose opioid prescriptions for chronic pain was the standard of care” along with concurrent benzodiazepine use. In contrast, only Dr. Stoddard has indicated that a [Bowflex] machine is medically necessary for [Hoffman], while Dr. Mattingly, Dr. Anden, and the medical panel simply agree that regular exercise would be beneficial to [Hoffman]. As such, the Court finds that a preponderance of the evidence demonstrates the potential benefits to [Hoffman] of regular exercise, but there is no such preponderance regarding the medical necessity of a [Bowflex] machine specifically. Similarly, there is no preponderance of evidence to support the medical necessity of a spinal cord stimulator, hot tub, or housekeeping service. ․ [B]ecause those courses of treatment were not recommended by the medical panel, and without an independent preponderance of the evidence to support them, the Court does not find these treatments “necessary” and Respondent[s] [are] not liable to cover those expenses.
The Court therefore finds that [Hoffman] is entitled to reimbursement for her out-of-pocket expenses for the historical use of the previously-recommended medications.
¶16 Hoffman then filed a “[m]otion for [r]eview as to certain selected aspects” of Judge Rammells decision. Hoffman claimed that the medical panels “conclusion as to the reasonableness or necessity of [her] past use of [o]xycodone is somewhat unclear, but given the Courts decision, Ms. Hoffman asserts her historical use of [o]xycodone should also be deemed compensable.” She also stated, “Presumably, until Hartford indicates a willingness to implement Dr. Jirickos and the panels recommendations (which the Court adopted), Ms. Hoffmans continuing use of [OxyContin] should be compensable.” She thus requested that the Board “clarify the compensability as to the continuing use of [OxyContin] and doctors’ appointments related thereto.”
The Boards Order
¶17 In February 2020, the Board issued an order modifying Judge Rammells decision. In it, the Board stated the following:
Ms. Hoffman contends that Judge Rammells order should be clarified to award her the cost of the medication she is currently prescribed until the point Delta is willing to pay for the program and the other treatment described by the panel to wean her from her dependence on opioids. After reviewing Judge Rammells decision in light of the medical evidence, the [Board] agrees with Ms. Hoffman that the order and award of benefits is lacking in enough specificity to allow reasonable reliance upon the order by the parties. ․ It appears that Judge Rammells award of benefits to Ms. Hoffman is based on the medical panels recommendations even if he did not specify the treatment outlined by the panel in the order.
The [Board] reads the panels conclusion on the issue of future medical care as providing two alternatives: first, the recommended weaning from opioids; and second, the 180 mg of morphine equivalent or 16 mg or less of buprenorphine per day. The [Board] views the reason for alternatives to be unimportant. Whether Ms. Hoffman hesitates to begin the weaning program or whether Delta somehow delays authorization for such program, the panel outlined the necessary pain medication for her work-related low-back condition.
With respect to Ms. Hoffmans past medical expenses—specifically the cost of her medication prescribed by her treating physicians—the [Board] finds that Delta is only liable for the amount determined to be “necessary” by the medical panel: 120 mg of extended release oxycodone without the benzodiazepine and Soma. The cases discussed by Judge Rammell involve circumstances that are distinct from the relatively simple issue in the present matter. As the parties acknowledge in their motions, Delta may stop payment for medical treatment upon the recommendation from Dr. Mattingly and assume the risk of liability if such treatment is ultimately found to be necessary and appropriate through adjudication before the Commission. In Ms. Hoffmans case, that appears to be what took place with the exception that the panel determined less medication was necessary than what had been prescribed by her treating physicians. The panels opinion regarding necessary medical treatment is persuasive as it represents a thorough and well-reasoned assessment of Ms. Hoffmans condition and because it is the product of collegial, impartial, and expert review of all of her relevant medical history. Thus, Ms. Hoffman is only entitled to the cost of past medical expenses consistent with the panels conclusions regarding what was necessary on an industrial basis.
(Internal footnote omitted.) In its order, the Board said,
The [Board] modifies the portion of Judge Rammells order ․ related to past medical expenses by awarding Ms. Hoffman only the cost of medical care determined to be necessary by the medical panel in this case. This includes the cost of the medication found necessary by the panel unless or until Ms. Hoffman undergoes the detoxification program and accompanying therapy outlined by the panel and Dr. Jiricko. Delta is liable for the cost of such treatment ․
¶18 Hoffman now seeks judicial review of the Boards decision.
ISSUES AND STANDARDS OF REVIEW
¶19 Hoffman asks us to determine whether the Boards findings of facts and conclusions of law with regard to her past and future medical expenses were supported by substantial evidence.
¶20 Utah law permits appellate courts to grant relief when a party is “substantially prejudiced” by an error in the “final agency action resulting from formal adjudicative proceedings.” Utah Code § 63G-4-403(1), (4). Our supreme court has explained that the applicable statute “lists several categories of remediable errors and implies a standard of review for some, but not all, of these errors.” Provo City v. Utah Labor Commn, 2015 UT 32, ¶ 8, 345 P.3d 1242. For example, “a challenge to an administrative agencys finding of fact is reviewed for substantial evidence.” Id.; see Utah Code § 63G-4-403(4)(g). But if substantial prejudice occurs because “the agency has erroneously interpreted or applied the law,” Utah Code § 63G-4-403(4)(d), “we employ one of our established standards of review for mixed questions of law and fact,” and “[t]he level of deference we afford to an agencys resolution of mixed questions varies depending upon the nature of the mixed question under review,” Provo City, 2015 UT 32, ¶ 9. Here, Hoffman alleges that “the particular conclusions at issue are more ‘factual’ than ‘legal’ and, thus, should be reviewed under the substantial evidence test.”
¶21 “A decision is supported by substantial evidence if there is a quantum and quality of relevant evidence that is adequate to convince a reasonable mind to support a conclusion.” Becker v. Sunset City, 2013 UT 51, ¶ 10, 309 P.3d 223 (cleaned up). “In conducting a substantial evidence review, we do not reweigh the evidence and independently choose which inferences we find to be the most reasonable.” Id. ¶ 21 (cleaned up). “Instead, we defer to [an administrative agencys] findings because when reasonably conflicting views arise, it is the [agencys] province to draw inferences and resolve these conflicts.” Id. (cleaned up).
ANALYSIS
¶22 Hoffman asks us to review the Boards order. She says she “believes some of the [Boards] decision[s] and conclusions are sound, but she also asserts some of the [Boards] decisions and conclusions are questionable and erroneous.”
¶23 First, Hoffman argues that the medical panels determinations as to past and future treatment are problematic because the panelists are not her treating physicians. Concerning past expenses, Hoffman “asserts her treating physicians were historically in the best position to make ․ judgment calls” about “what kind of opioid pain medication and how much” was appropriate for her “as they worked with Ms. Hoffman to get her type and levels of prescription opioid pain medication properly calibrated so she could function on a limited but stable basis.” Regarding future treatment, Hoffman argues that a “medical panels recommendations become problematic because members of a panel are not the treating physicians and do not have any history with the claimant and are not able to follow the claimants response to any particular treatment.” Hoffman asserts that a “treating physician is in the best position to make and implement and monitor recommended future treatment.”
¶24 But the role of a medical panel is well settled by statute and caselaw. Utah Code section 34A-2-601 establishes that “[a]n administrative law judge may base the administrative law judges finding and decision on the report of ․ a medical panel.” Utah Code § 34A-2-601(2)(e)(i). Even if treating physicians are best positioned to prescribe and adjust a treatment plan, this reality would not render a medical panels conclusions and recommendations legally impotent. Indeed, we have “note[d] that a medical panels report alone can be enough to conclude that the Commissions determination was supported by substantial evidence.” Morris v. Labor Commn, 2021 UT App 131, ¶ 17, 503 P.3d 519 (cleaned up), cert. denied, 509 P.3d 768 (Utah 2022). “After all, the [applicable statute] expressly permits the Commission to base its findings on a medical panels report, and we will not question the Commissions decision to do so where, as here, the reports are thorough and prepared by neutral medical experts.” Id. (cleaned up).
¶25 Hoffman does not assert that the panels report was not thorough or that it was not prepared by “neutral medical experts.” Id. She does not take issue with the Boards or Judge Rammells findings about the reliability of the panels report. The Board indicated that “[t]he panels opinion regarding necessary medical treatment is persuasive as it represents a thorough and well-reasoned assessment of Ms. Hoffmans condition and because it is the product of collegial, impartial, and expert review of all of her relevant medical history.” And Judge Rammell declared that “the [medical panel report] is the product of thorough, collegial, and impartial review, both of the entire medical record and of [Hoffman] herself” and “that the panels findings [were] reliable and its treatment recommendations appropriate.” We have no reason to disregard the panels recommendations. “Accordingly, if the Commissions decision is supported by the medical panel reports, the substantial evidence standard is satisfied.” Id.; see also Valdez v. Labor Commn, 2017 UT App 64, ¶ 22, 397 P.3d 753, cert. denied, 400 P.3d 1046 (Utah 2017); Hutchings v. Labor Commn, 2016 UT App 160, ¶ 32, 378 P.3d 1273, cert. denied, 390 P.3d 720 (Utah 2017); Cook v. Labor Commn, 2013 UT App 286, ¶ 18, 317 P.3d 464. Again, “in conducting a substantial evidence review, we do not reweigh the evidence and independently choose which inferences we find to be the most reasonable.” Becker v. Sunset City, 2013 UT 51, ¶ 21, 309 P.3d 223 (cleaned up). Therefore, we reject Hoffmans arguments that the medical panels determinations regarding past and future treatment are problematic merely because the panelists are not her treating physicians.
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¶26 In her reply brief, Hoffman attempts to present her argument differently, saying she “recognizes that [the Commissions] current process to resolve medical controversies is to use medical panels and that the current state of the law is that, where [the Commissions] decision is supported by a medical panel report, the Commission can satisfy the substantial evidence test.” She asserts that this legal landscape “simply frames the inquiry in the instant appeal as being whether the [Boards] findings and decision on the issue ․ are supported by the medical panel report. If they are not, the [Boards] findings are not supported by substantial evidence.” Thus, Hoffman presents her argument as claiming “not that the [Board] should have allowed higher dosages of opioid pain relief medication, but that, as to the level of opioids which the medical panel found necessary and appropriate (after a structured weaning down process, at least going forward), whether Hartford should be paying for such lower level of opioid use.”
I. Past Expenses
¶27 On the topic of past expenses, Hoffman declares that “[t]he panel offered no opinion as to the compensability of such pain medication which Ms. Hoffman has been prescribed and used in the past.”
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Hoffman is incorrect. While the panel did not use the word “compensable” related to its findings on what past medical care was necessary, it did make findings on the topic, which the Board properly relied on in determining the compensability of Hoffmans past care. As presented to the panel, the question of what past care Hoffman needed was clearly a question of what level of past care Respondents were liable for.
¶28 Hoffman herself acknowledges in her opening brief that, “[t]o be sure, a workers’ compensation carrier can terminate ongoing medical care and medications as being unreasonable or unnecessary[
5
] ․ , but if a carrier does so before the Commission authorizes it to do so, the carrier bears the risk of getting stuck with the bill.” The Board stated that “[i]n Ms. Hoffmans case, that appears to be what took place” but that ultimately “the panel determined less medication was necessary than what had been prescribed by her treating physicians.” Of course, the risk associated with seeking medical care not predetermined to be necessary flows in both directions. Just as an employer may be “stuck with the bill” if the care is later determined to have been necessary, so too may an employee face out-of-pocket expenses that may be later determined to be non-reimbursable. Cf. Benge v. Cody Ekker Constr., 2019 UT App 164, ¶ 20, 451 P.3d 667 (declining to disturb the Commissions denial of coverage for two knee surgeries—despite an earlier surgery being covered—because a medical panel found that the later surgeries were not related to or caused by the empolyees workplace injury). We do not condone Hartfords actions of cutting off all payments for Hoffmans medical expenses or, more generally, the actions of some employers or insurance carriers who leave injured employees to pay costs out of pocket and seek redress. See Harding v. Industrial Commn of Utah, 28 P.2d 182, 184 (1934) (“The insurance carrier ․ ought not wait until full investigation has been made before providing necessary care and treatment for injured [employees].”). However, from the time of the first defense exam, Hoffman was on notice that she might lose coverage for some or even all of her opioid medications. She could have—at any point afterward—gone through a weaning program and then sought reimbursement for it from Hartford. She did not do so. At any rate, when the panel was asked what past care was necessary to treat Hoffmans industrial injury, this was a question about what level of past care Respondents were liable for.
¶29 Hoffman attempts to split hairs by asserting that the medical panel determined what was necessary but not what was compensable, but in this context, they are one and the same. Judge Trayners order indicates that Hoffman “claimed entitlement to ․ medical expenses” and that the “only issues before the Court [were] necessary medical care from 2016 to the present and recommended medical care to treat [Hoffmans] industrial ․ condition.” Her memo to the medical panel made it clear that she was referring the case to the panel to settle the disputes on these two questions. And the medical panels report cannot be fairly interpreted as opining on any other topic than the care necessary for Hoffman that she is entitled to coverage for. Given these facts and the statutory backdrop that an “employer or the [employers] insurance carrier shall pay reasonable sums for medical, nurse, and hospital services [and] for medicines ․ necessary to treat the injured employee,” Utah Code § 34A-2-418(1), Hoffmans attempt to paint the panels findings on past care as distinct from findings on compensability is unavailing.
¶30 The Boards decision is supported by the medical panels report, so it is therefore supported by substantial evidence. See Morris v. Labor Commn, 2021 UT App 131, ¶ 17, 503 P.3d 519, cert. denied, 509 P.3d 768 (Utah 2022). We acknowledge that the medical panels report is not the picture of clarity—particularly concerning past care, about which the panel introduces unnecessary confusion by using present and future tense verbiage. But the report definitively states that the panel has “decided that [Hoffman] ‘needed’ the 120 mg of OxyContin (extended release oxycodone) a day.” It also states that “the benzodiazepine and Soma are clearly not medically necessary and are not indicated to treat chronic pain” and that “[t]he oxycodone 30 mg 5X/day is excessive and not medically indicated.” The Boards findings are consistent with these: “With respect to Ms. Hoffmans past medical expenses[,] ․ the [Board] finds that Delta is only liable for the amount determined to be ‘necessary’ by the medical panel: 120 mg of extended release oxycodone without the benzodiazepine and Soma.” Therefore, the Boards findings satisfy the substantial evidence standard. See id. (“Accordingly, if the Commissions decision is supported by the medical panel reports, the substantial evidence standard is satisfied.”).
II. Future Medication Expenses
¶31 We next decide whether the Boards determination regarding the compensability of future medications is supported by substantial evidence.
¶32 The Board stated that it “reads the panels conclusion on the issue of future medical care as providing two alternatives: first, the recommended weaning from opioids; and second, the 180 mg of morphine equivalent or 16 mg or less of buprenorphine per day.” This much is clearly supported by the medical panels report:
We believe that Dr. Jirickos plan is the most ideal. ․ If [Hoffman] is unwilling to wean off her opioids, these are our recommendations:
1. Wean down to 180 mg of morphine equivalent dose a day (which is 90–120 mg oxycodone per day depending on [the] conversion ratio chosen). This can be a variation of OxyContin only, oxycodone only[,] or a combination of OxyContin and oxycodone.
Or
2. Switch to Buprenorphine 16 mg or less a day.
Regardless of which path she and her physician decide, she needs to stop using the benzodiazepine and Soma along with her opioid.
Because the Boards conclusion on this point is supported by the medical panels report, it is supported by substantial evidence. See Morris v. Labor Commn, 2021 UT App 131, ¶ 17, 503 P.3d 519, cert. denied, 509 P.3d 768 (Utah 2022).
¶33 The Board further stated that it “views the reason for alternatives to be unimportant.” It said, “Whether Ms. Hoffman hesitates to begin the weaning program or whether Delta somehow delays authorization for such program, the panel outlined the necessary pain medication for her work-related low-back condition.” At first glance, it may appear that the Board diverges from the panels recommendation that Respondents provide Hoffman with an opportunity to wean by implicitly deciding that the alternative options for coverage below Hoffmans current medication levels engage immediately. However, the Board is clear that Respondents are still liable for covering the costs associated with a weaning program if Hoffman engages in one, adding a footnote stating, “[I]f, as Ms. Hoffman seems to imply, she wants to undergo the detoxification program with accompanying therapy recommended by the panel but Delta delays in paying for it, Ms. Hoffman can seek to enforce the award of the cost of such treatment through the courts.” Accordingly, the Boards conclusions about the compensability of future medication expenses are supported by the medical panels report and are therefore supported by substantial evidence. Id.
¶34 As to Hoffmans future use of benzodiazepine and Soma, the Board impliedly denies future coverage of these medications in line with the medical panels recommendations. However, the panel also referred to other medications: “There are better medications to treat her anxiety and sleep disorder with less risk profile.” The Boards decision does not deny these other medications, so it affirmed Judge Rammells ruling in this respect. Judge Rammell ruled that Respondents are “obligated to pay for the expenses associated with the recommended future treatment” according to “the medical panels recommendations,” presumably including this recommendation. So, while Respondents are not liable for the future cost of benzodiazepine and Soma, they are responsible for the cost of more-effective, lower-risk medications to treat Hoffmans anxiety and sleep disorder.
III. Other Treatments
¶35 Hoffman asserts that expenses for “additional medical treatment modalities,” including a home exercise machine and housekeeping, are reasonable. On this point, the Board affirmed Judge Rammells decision that stated,
[A] preponderance of the evidence demonstrates the potential benefits to [Hoffman] of regular exercise, but there is no such preponderance regarding the medical necessity of a [Bowflex] machine specifically. Similarly, there is no preponderance of evidence to support the medical necessity of a spinal cord stimulator, hot tub, or housekeeping service. Thus, ․ because those courses of treatment were not recommended by the medical panel, and without an independent preponderance of the evidence to support them, the Court does not find these treatments “necessary” and Respondent[s] [are] not liable to cover those expenses.
¶36 The Boards denial of coverage for these other treatments is supported by the medical panels recommendations:
We do not believe she would benefit from the spinal cord stimulator to improve function or reduce medication. ․
We do not believe a [Bowflex] machine is medically indicated. Exercise is indicated and recommended, but virtually all forms of exercise are helpful (walking, swimming, core strength, yoga, etc.), but a specific brand name device is not needed.
We do not believe she would benefit from a hot tub. There is no scientific evidence to suggest hot tubs improve function or help chronic low back pain.
We do not believe housekeeping is medically necessary for her low back pain. She currently chooses to employ housekeeping services, but her current yard and animal care have similar physical requirements. Having housekeeping has not improved her function[,] nor has it allowed her to reduce her opioid use.
Because the Boards conclusions are supported by the medical panels report, they are supported by substantial evidence. See Morris v. Labor Commn, 2021 UT App 131, ¶ 17, 503 P.3d 519, cert. denied, 509 P.3d 768 (Utah 2022).
¶37 But again, the Boards decision did not deny other treatments recommended by the medical panel or ordered by Judge Rammell. Judge Rammell ruled that Respondents are “obligated to pay for the expenses associated with the recommended future treatment” according to “the medical panels recommendations.” The panel recommended “a [p]sychiatry evaluation to treat [Hoffmans] anxiety from the chronic pain and [a] [s]leep specialist evaluation to treat her sleep disorder from chronic pain.” The panel also stated, more generally, that as to future care, “Dr. Jirickos plan is the most ideal.” Dr. Jirickos plan included recommendations for “a robust cognitive behavioral therapy training ․ and psychiatric evaluation for anxiety and medication management. Also, 10 to 12 sessions of physical therapy for [Hoffmans] right leg.” Accordingly, all of these treatments were impliedly recommended by the medical panel, ordered by Judge Rammell, and approved by the Board. So Respondents are responsible for the costs associated with these other treatments, if Hoffman undergoes them.
CONCLUSION
¶38 The Boards decision is supported by substantial evidence. Accordingly, we decline to disturb it.
FOOTNOTES
1
. We recognize that the medical panels report phrased this question confusingly. Judge Trayners memo to the medical panel asked, “What past medical care since 2016 been [sic] necessary to treat the Petitioners 1986 industrial back injury?” The panels wording further muddies already murky waters. But regardless of the wording, the panel understood that it was asked to determine what past care was necessary between 2016 and the time of the panels analysis.
2
. In reaching this conclusion, Judge Rammell relied on two previous decisions by the Board: Pakalani-Raber v. Convergys Corp., No. 16-0316, 2017 WL 6818274, at *3 (Utah Labor Commn Dec. 5, 2017) (determining that a petitioner “properly relied on her treating physicians recommendations regarding opioid pain medication as awarded to her through the adjudication of her previous claim” and concluding that “[t]o deny a claim for medical benefits that were deemed necessary by a medical panel in the previous case after the fact would not be appropriate”), and Tacy v. Kennecott, No. 15-0370, 2018 WL 6018509, at *1–2 (Utah Labor Commn Sept. 11, 2018) (reciting how, after a medical panel modified its earlier opinion to no longer recommend a benzodiazepine and to recommend a lower dosage of opioid use or complete weaning, an ALJ “relied on the panels clarified opinion and awarded [the petitioner] the past expenses for opioid and benzodiazepine medications along with the cost of a program to wean him from such medications”). Judge Rammell acknowledged that the decisions were not on all fours with Hoffmans case but stated that “the underlying principle[s]” of the decisions “remain[ ] applicable” such that “[a] medical panels later conclusions of excessive dosage should not be retroactively applied to punish [Hoffman] for following her physicians advice prior to the panels involvement.” We observe that the fact of a previous medical panel report in both decisions is critical. Here Hoffmans past opioid use above the level the medical panel deemed “necessary” was not based on a previous recommendation by a medical panel. In Judge Rammells words, “[A] respondents liability for ․ treatment does not extend beyond the care recommended in an adopted medical panel report.” Here, Respondents’ liability for Hoffmans past medical care does not extend beyond the medical panels determination as to which portion of that care was necessary.
3
. Hoffman also takes issue with statements in the medical panels report concerning the medical or clinical findings that supported the panels assessment. She argues that the medical panels determination that her pain level or function did not change when her dosage was increased or decreased was not accurate.Additionally, she disagrees with the medical panel about what level of opiates are necessary, saying that the panel declared the level of pain medication she was taking was “not really necessary because the later reduction of such prescription opioid pain medication did not kill her.” She counters, “If life or death were to be the gauge for whether a medical treatment is reasonable (and whether the expense for such treatment is a ‘reasonable’ medical expense), insurance companies wouldnt have to pay anything.”But we do not address the medical panels findings directly because Hoffman has not presented for our review the question of whether the Board abused its discretion in adopting the medical panels report. See Bade-Brown v. Labor Commn, 2016 UT App 65, ¶¶ 8–10, 372 P.3d 44. And, as noted, “if the Commissions decision is supported by the medical panel reports, the substantial evidence standard is satisfied.” Morris v. Labor Commn, 2021 UT App 131, ¶ 17, 503 P.3d 519, cert. denied, 509 P.3d 768 (Utah 2022). Therefore, Hoffmans arguments on these points are unavailing.
4
. On this point, Hoffman asserts that Judge Rammell appropriately “found that ‘[Hoffman] properly relied on her treating physicians’ recommendations at the time’ and, then discussing and applying the precedents in [the two Board decisions discussed supra note 2] and adopting the same reasoning to govern his decision on the issue, he decided: ‘A medical panels later conclusions of excessive dosage should not be retroactively applied to punish [Hoffman] for following her physicians advice prior to the panels involvement.’ ” We do not opine further on Judge Rammells analysis because the Boards decision is “the final agency action resulting from formal adjudicative proceedings” that has been presented to us for judicial review. See Utah Code § 63G-4-403(1).But we note that inasmuch as both Judge Rammell and the Board relied on the medical panel in reaching different conclusions about compensability, this is not the first time an ALJ and the Board have disagreed in their reading of a medical panel report. In YESCO v. Labor Commission, 2021 UT App 96, 497 P.3d 839, an ALJ relied on a medical panel report to determine that two injuries an employee suffered “were degenerative and/or congenital and not caused by a work-related activity.” Id. ¶ 8 (cleaned up). “On review, the [Board] read the medical panels report differently than the ALJ did.” Id. ¶ 9 (cleaned up). “From the [Boards] perspective, the panels report medically causally connected [the employees] work activities to his” injuries. Id. (cleaned up). “Accordingly, the [Board] remanded the case to the ALJ for further consideration,” and “[t]he ALJ awarded [the employee] benefits on remand, largely echoing the [Boards] conclusions regarding medical causation.” Id. On judicial review, this court highlighted that, “as the [Board] noted, [a] ‘clear inference’ from the medical panels statement ․ , combined with the other opinions in the record, support[ed] the [Boards] medical causation finding.” Id. ¶ 22. Thus, our conclusion that the Boards decision is supported by the medical panels report ends our inquiry despite differences in interpretation of the medical panels report between Judge Rammell and the Board.
5
. Hoffmans situation is somewhat unique in that the parties had previously entered into a stipulation wherein Hartford agreed “to continue paying reasonable medical expenses related to the accepted injuries.” Until Dr. Mattinglys defense exam, Hartford paid for the medical treatments that Hoffmans treating physicians prescribed. In other words, for some thirty years, Respondents indicated through their actions that the treatments prescribed by Hoffmans physicians were reasonable. After Dr. Mattinglys defense exam, Respondents presumably believed that those treatments were no longer reasonable and ceased paying for them. We are sympathetic to Hoffman in that her reliance on high levels of opioids began and continued for some time with Hartfords apparent acceptance. And we note the unrebutted assertion that, in Judge Rammells words, “when [Hoffman] began taking this combination of medications for which she now seeks reimbursement, ‘․ high dose opioid prescriptions for chronic pain was the standard of care’ along with concurrent benzodiazepine use.” Accordingly, the medical panel could have determined that Hoffmans historic use of opioids was medically necessary, and we would decline to disturb the Commissions decision if it had relied on such a conclusion. But the panel did not so conclude.Furthermore, while we observe that, generally, what is reasonable may include more than what is necessary, the question of whether the language of the stipulation (“reasonable medical expenses related to the accepted injuries”) and of the Utah Code (“reasonable sums for medical, nurse, and hospital services [and] for medicines ․ necessary to treat the injured employee”), see Utah Code § 34A-2-418(1), align is not properly before us. And Hoffman has not sought reimbursement through an enforcement action of the parties’ stipulation or on a theory of equitable estoppel by arguing that care deemed unnecessary by the Board may still have been “reasonable” for the purposes of the parties’ stipulation or that she reasonably relied on the stipulation and Respondents’ past acts. See Benge v. Cody Ekker Constr., 2019 UT App 164, ¶ 20, 451 P.3d 667. We address only the question before us: whether the Boards findings regarding necessary medical care were supported by substantial evidence. And based on the Boards proper reliance on the medical panels conclusions, the Boards findings are indeed supported by substantial evidence.
MORTENSEN, Judge:
JUDGE DAVID N. MORTENSEN authored this Opinion, in which JUDGES GREGORY K. ORME and MICHELE M. CHRISTIANSEN FORSTER concurred.