Employee entitled to erectile dysfunction medication even though not meeting criteria of Utilization

Ex parte Ward International, 24 ALW 37-7 (Ala. Civ. App. 2015) (click here for full text of opinion) was released September 4, 2015. In that case, the employee, Wesley Shows, requested approval for treatment of erectile dysfunction. The employer refused to provide the medication because it did not meet the criteria of Utilization Review Rule 480-5-5-.15(15) (click here for a copy of full text of UR section). Shows filed a Motion to Compel the employer to pay for the medication. Shows supported his motion with correspondence from his authorized treating physician, Dr. Wayne Cockrell, who stated that Shows suffered from chronic pain due to his work-related injury and that treatment of Shows erectile dysfunction "is indicated in association with Shows' work-related injury."

The employer did not contest the authorized physician's opinion relating the erectile dysfunction to the injury. Instead, the employer argued that Shows' erectile dysfunction condition did NOT fall within the specifically enumerated conditions identified in Rule 480-5-5-.15(15) for "ERECTILE DYSFUNCTION MEDICATION." Rule 480-5-5-.15(15) was promulgated pursuant to the authorizty conferred by Section 25-5-293.

It was undisputed that Shows did not suffer any of the six conditions that may result in organic erectile dysfunction enumerated in Rule 480-5-5-.15(15).

The Court relied upon Ex parte Southeast Alabama Med. Ctr., 835 So. 2d 1042, 1054-55 (Ala. Civ. App 2002) in stating that "The employee's right to reasonably necessary medical treatment is not a right that derives in any manner from the provisions of § 25–5–293(k) or the regulations promulgated thereunder. ... [T]he employee's rights are rights that are granted directly to the employee, in every case, by legislative enactment: § 25–5–77(a)."

The Ward Court held that "Section 25-5-77(a) makes Ward responsible for reasonably necessary medical treatment of conditions that are caused by the accident arising out of and in the course of Shows's employment. That is so, notwithstanding the blanket prohibition in Rule 480-5-5-.15(15) on treating erectile dysfunction that is not considered to be an "organic," as opposed to a "psychiatric" or "psychological," condition resulting from one the 6 enumerated conditions, as well as the prohibition on prescribing more than 5 tablets in any 30-day period"