JCC Awards PT and Epidural After 120-Day Rule Waives MCC Defense

In Jorge Acosta v. American Airlines Inc/Sedgwick CMS, OJCC Case No. 24-017417WJH, the claimant sought physical therapy and an epidural injection for low-back complaints after a May 17, 2024 lifting accident. The employer and servicing agent defended on medical necessity, causal relation, major contributing cause, and equitable-estoppel theories tied to the claimant's prior lumbar surgery and degenerative spine condition.

Judge Walter J. Havers accepted the opinions of Dr. Rafael Fernandez and Dr. Mark Eskenazi that the work accident caused only a temporary exacerbation and that the claimant's need for further low-back treatment was driven by his preexisting post-laminectomy condition. Even so, the order holds the employer and servicing agent waived that defense under section 440.20(4) by continuing to authorize care with Dr. Eskenazi long after the original 120-day pay-and-investigate window had expired, without proving a new timely reservation of rights.

That waiver controlled the result. The JCC ordered the employer and servicing agent to provide physical therapy and an epidural injection, and also awarded claimant's counsel entitlement to employer/carrier-paid attorney's fees and costs for securing those benefits. The decision is a useful reminder that a carrier can lose an otherwise strong MCC position if its post-denial authorization history is inconsistent with the 120-day rule.

Source: Compensation Order