Amended July 19, 2016 Deanna Jo Ramirez-Trujillo v. Quality Egg, L.L.C., Wright County Egg Division, and Selective Insurance Company of America

IN THE SUPREME COURT OF IOWA
No. 14–0640

Filed April 15, 2016

Amended July 19, 2016

DEANNA JO RAMIREZ-TRUJILLO,

Appellant,

vs.

QUALITY EGG, L.L.C., WRIGHT COUNTY EGG DIVISION, and
SELECTIVE INSURANCE COMPANY OF AMERICA,

Appellees.

On review from the Iowa Court of Appeals.

Appeal from the Iowa District Court for Polk County, Scott D.

Rosenberg, Judge.

Both parties seek further review of a court of appeals decision

upholding a ruling of the Workers’ Compensation Commission.

DECISION OF COURT OF APPEALS AFFIRMED IN PART AND
VACATED IN PART; DISTRICT COURT JUDGMENT AFFIRMED IN

PART AND REVERSED IN PART; CASE REMANDED WITH

INSTRUCTIONS.

Mark S. Soldat of Soldat, Parrish-Sams & Gustafson, PLC,

West Des Moines, for appellant.

Richard G. Book of Huber, Book, Cortese & Lanz P.L.L.C.,

West Des Moines, for appellees.
 2

WIGGINS, Justice.

An employee injured her back at work. Her employer

acknowledged its liability for the injury and authorized care. The

employer paid for the cost of the care the employee received to treat the

back injury through September 30, 2009. The employee brought a

workers’ compensation claim seeking reimbursement of medical

expenses she incurred for additional back treatment between May 2010

and April 2011 and workers’ compensation benefits for the same period.

The employer argued it did not authorize the medical expenses the

employee incurred between May 2010 and April 2011. The employer also

maintained the expenses did not have a causal connection to her

compensable workplace injury. The workers’ compensation

commissioner concluded the treatment the employee received between

May 2010 and April 2011 was not causally related to her workplace

injury. However, the commissioner held the employer was liable for the

claimed medical expenses because the employer failed to notify the

employee it was no longer authorizing care as required by Iowa Code

section 85.27(4) (2009). Both parties sought judicial review.

The district court reversed the final agency decision in part,

concluding the agency misinterpreted section 85.27(4). Both parties

appealed, and we transferred the case to the court of appeals. The court

of appeals reversed the district court in part, concluding the district

court erroneously interpreted section 85.27(4).

Both parties sought further review, which we granted. On further

review, we will let the court of appeals decision stand as the final

decision of this court to the extent it affirmed the district court decision

affirming in part the final agency decision. However, we find the

commissioner erroneously interpreted Iowa Code section 85.27(4).
 3

Accordingly, we affirm in part and vacate in part the decision of the court

of appeals, affirm in part and reverse in part the district court judgment,

and remand the case to the district court with instructions to remand the

case to the commissioner for further proceedings consistent with this

opinion.

I. Background Facts and Proceedings.

On August 1, 2009, Deanna Ramirez-Trujillo slipped on an egg on

the floor at her workplace in Clarion, Iowa. Although Ramirez-Trujillo

managed to catch herself and did not fall to the floor, she injured her

back. Her employer, Quality Egg, L.L.C., Wright County Egg Division,

completed an incident report acknowledging her workplace injury.

Quality Egg authorized Wright Medical Center to evaluate and treat

Ramirez-Trujillo. Physician assistants at Wright Medical Center treated

Ramirez-Trujillo for acute low back strain and severe muscle spasms on

August 3, 7, 13, 21, and 31. At each visit, Ramirez-Trujillo signed the

bottom of the authorization form to release her medical records to

Quality Egg and its insurer, Selective Insurance Company of America.

After her August 3 visit, her health care provider released her to return to

work with restrictions.

Throughout the months of August and September, Ramirez-Trujillo

received prescription medications, transcutaneous electrical nerve

stimulation treatment, and physical therapy. Though she received an

authorization form from Quality Egg each time she saw a physician

assistant at Wright Medical Center, she did not receive any authorization

forms for her physical therapy appointments. On September 30,

Ramirez-Trujillo had a follow-up appointment with a physician assistant

at Wright Medical Center. Quality Egg once again authorized Wright

Medical Center to evaluate and treat Ramirez-Trujillo, and she once
 4

again signed the authorization form to release her medical records to

Quality Egg and its insurer. The physician assistant released Ramirez-

Trujillo to full duty without any work restrictions. The physician

assistant’s notes indicated Ramirez-Trujillo’s back strain was resolving

and no follow-up care was required. The notes also indicated Ramirez-

Trujillo could return to the clinic should further problems arise.

On December 26, Ramirez-Trujillo sought treatment for low back

pain radiating up to her head and down to her toes at the emergency

room at Wright Medical Center. She received an injection, prescriptions

for several medications, and a temporary work release. The physician

assistant’s notes indicated Ramirez-Trujillo said the pain had begun after

she shoveled snow the previous day. She returned to work on

December 29.

On May 1, 2010, Ramirez-Trujillo again sought treatment for low

back pain at the emergency room at Wright Medical Center. She received

two injections, prescriptions for several medications, and a temporary

work release. The treating physician advised Ramirez-Trujillo to seek

follow-up care in one week. The physician’s notes acknowledged

Ramirez-Trujillo’s historical problems with back pain and indicated there

had been no clear triggers for her pain that day.

Over the next several weeks, Ramirez-Trujillo received follow-up

care from a physician assistant and a doctor at Wright Medical Center.

She began physical therapy and continued to take prescription

medication. On May 17, Ramirez-Trujillo reported her pain was gone

and she felt ready to return to work. The doctor released her to full duty

without work restrictions. During a follow-up appointment on June 9,

however, Ramirez-Trujillo reported she was still experiencing intermittent

low back pain and muscle spasms.
 5

On June 13, Ramirez-Trujillo again sought treatment at the

emergency room at Wright Medical Center. An x-ray of her lumbar spine

showed disc space narrowing at L5-S1. Her treating physician

prescribed medication and instructed her to seek follow-up care. The

physician’s notes indicated Ramirez-Trujillo said she had been

experiencing intermittent back pain since she injured her back when she

slipped on an egg at work.

On June 14, Ramirez-Trujillo sought follow-up care at Wright

Medical Center. The doctor who treated Ramirez-Trujillo ordered an MRI,

which revealed a prominent disc extrusion with mild to moderate spinal

stenosis at L5-S1. The doctor’s notes indicated Ramirez-Trujillo said she

had previously injured her back at work but characterized her recent

pain as a separate episode. The notes also indicated Ramirez-Trujillo

expressly stated “this is not workman’s comp.” The doctor referred

Ramirez-Trujillo to orthopedic surgeon Mark Palit.

On June 28, Dr. Palit saw Ramirez-Trujillo at Wright Medical

Center and administered a steroid injection. On July 19, Dr. Palit saw

Ramirez-Trujillo at a follow-up appointment. Because Ramirez-Trujillo

reported she continued to experience severe pain, Dr. Palit offered to

perform decompression surgery. Dr. Palit’s notes indicated Ramirez-

Trujillo told him the August 2009 slip injury had resolved with

conservative care by October 2009 and said she did well until May 2010

when she was going up some stairs and her back locked up.

On August 4, Dr. Palit performed decompression surgery on

Ramirez-Trujillo. Dr. Palit discharged her from Wright Medical Center

the following day. Ten days later, she sought treatment at the emergency

room at Wright Medical Center due to drainage occurring at the surgical

site and received an antibiotic to treat cellulitis. Ramirez-Trujillo
 6

attended follow-up appointments with Dr. Palit at Wright Medical Center

in August, September, and October. Ramirez-Trujillo sought further

treatment in November and December for increased pain in her back

radiating to her right hip and foot. Dr. Palit prescribed medication and

physical therapy. Between the date of the surgery and the end of the

year, she received three temporary work releases from Dr. Palit.

However, each work release covered only a few days.

At a follow-up appointment on January 3, 2011, Dr. Palit imposed

work restrictions on Ramirez-Trujillo and ordered another MRI of her

lumbar spine due to her continuing pain. The MRI revealed a recurrent

disk protrusion at L5-S1. Ramirez-Trujillo attended several additional

follow-up appointments during January and February, during which she

received prescriptions and a steroid injection. On March 23, Dr. Palit

performed a revision of the decompression surgery. He discharged

Ramirez-Trujillo from Wright Medical Center the following day.

This appeal follows from a notice and petition Ramirez-Trujillo filed

with the workers’ compensation commissioner against her employer and

its insurer 1 on October 13, 2010. She sought workers’ compensation

benefits, penalty benefits, and medical expenses she incurred from May
2010 through April 2011. 2 Quality Egg stipulated Ramirez-Trujillo

sustained an injury in the course of her employment on August 1, 2009,

that caused her a temporary disability. Additionally, Quality Egg

stipulated the treatment Ramirez-Trujillo received was reasonable and

necessary and the fees charged by her care providers were fair and

1Throughout the remainder of this opinion, “Quality Egg” refers to Ramirez-

Trujillo’s employer and its insurer.
2Ramirez-Trujillo did not seek reimbursement of the medical expenses she

incurred during December 2009.
 7

reasonable. Quality Egg argued it did not authorize the medical

expenses Ramirez-Trujillo incurred between May 2010 and April 2011.

Quality Egg also argued those medical expenses did not have a causal

connection to her compensable workplace injury. However, Quality Egg

did not dispute the medical expenses Ramirez-Trujillo incurred were at

least causally connected to the medical condition upon which her claim

of injury was based.

The evidence presented at the arbitration hearing established

medical providers treated Ramirez-Trujillo for low back strains and

spasms on several occasions dating back to the time when she was

eleven years old, but that her prior back issues had resolved before her

August 2009 work injury. 3

Ramirez-Trujillo submitted a written evaluation and report

prepared by Dr. Robin Epp, a certified independent medical examiner.

Based on a physical examination of Ramirez-Trujillo and a review of her

medical records, Dr. Epp concluded Ramirez-Trujillo’s back condition

and the treatment she received after September 30, 2009, were directly

and causally related to her work injury and her subsequent work

activities. Ramirez-Trujillo’s testimony and other testimony by lay
witnesses supported Dr. Epp’s opinion.

Quality Egg submitted a written medical opinion prepared by

Dr. Donna Bahls. Based on her review of a portion of Ramirez-Trujillo’s

medical records, Dr. Bahls concluded neither the work injury nor

Ramirez-Trujillo’s subsequent work activities contributed to the periods

3Ramirez-Trujillo had previously visited Wright Medical Center for treatment of
back pain even before she began working for Quality Egg. In January 2006, Ramirez-
Trujillo went to the emergency room at Wright Medical Center, complaining of lower
back pain after slipping and falling on ice.
 8

of disability she experienced after the December 2009 shoveling incident.

Dr. Bahls further concluded neither the work injury nor Ramirez-

Trujillo’s subsequent work activities prior to the shoveling incident

caused her disk to herniate. Rather, Dr. Bahls concluded the shoveling

incident or other events Ramirez-Trujillo mentioned to her doctors

caused the periods of disability she experienced and the medical care she

received on and after December 26, 2009.

Quality Egg also submitted an exhibit on which Dr. Palit indicated

his agreement with the following statement:

Dr. Palit do you agree that it is your opinion that you cannot
state with reasonable medical certainty that the central and
right paracentral prominent disc extrusion at L5-S1 with
mild to moderate stenosis shown on the MRI, the symptoms
reported by Ms. Ramirez-Trujillo in May-July 2010, the
herniated nucleus pulposus at L5-S1 that you diagnosed,
the surgery you performed on August 4, 2010 described as
an L5-S1 bilateral hemilaminotomy, foraminotomy and
discectomy and the revision of the L5-S1 surgery that you
performed were caused by or related to the injury of
August 1, 2009?

Two employees testified and submitted written statements on

behalf of Quality Egg, including one employee who was Ramirez-Trujillo’s

supervisor and another who was her coworker. Both employees testified
to hearing Ramirez-Trujillo state she had slipped or fallen on some stairs

at home. 4 In addition, Ramirez-Trujillo’s supervisor testified regarding

various conversations he claimed to have had with her in which she

admitted the condition she was seeking treatment for at the time was not

work-related.

4Though Ramirez-Trujillo admitted her back once locked up as she walked up
the three stairs outside her home, she denied ever having fallen down them. Her
testimony suggested those were the only stairs at her home.
 9

The deputy commissioner issued an arbitration decision

extensively summarizing the above facts and testimony. The arbitration

decision expressly addressed the credibility of the witnesses, including

both the lay witnesses who testified and the expert witnesses whose

reports the parties submitted as exhibits. The deputy commissioner also

made numerous legal conclusions, one of which is particularly relevant

to this appeal. Namely, the deputy commissioner concluded Ramirez-

Trujillo’s condition after September 30, 2009, was not the result of her

August 2009 work injury. The deputy commissioner thus denied

Ramirez-Trujillo’s claims for workers’ compensation benefits and medical

expenses incurred after September 30, 2009.

Ramirez-Trujillo appealed to the workers’ compensation

commissioner. The appeal decision affirmed and adopted the majority of

the arbitration decision, noting the hearing deputy’s findings of fact and

conclusions of law could be adequately separated for review on appeal

and giving deference to the hearing deputy’s credibility assessments.

The appeal decision thus affirmed the hearing deputy’s conclusion that

the medical expenses Ramirez-Trujillo incurred from May 2010 through

April 2011 were not causally related to the August 2009 work injury.

However, the appeal decision nonetheless awarded Ramirez-Trujillo the

medical expenses she incurred from May 2010 through April 2011 and

associated transportation expenses because she incurred them while

seeking care from providers Quality Egg authorized and because Quality

Egg conceded it failed to notify her it was not authorizing further

treatment. The commissioner interpreted Iowa Code section 85.27(4) to

require an employer to cover the cost of authorized care unless the

employer satisfies its duty to monitor the care it authorizes and its duty
 10

to notify the employee when further care is no longer authorized, even if

the care provided is ultimately found to be unrelated to the work injury.

Quality Egg sought judicial review of the portion of the final agency

decision ordering it to reimburse and hold Ramirez-Trujillo harmless for

medical expenses she incurred after September 30, 2009. Ramirez-

Trujillo asserted the agency erred in failing to comply with Iowa Code

section 17A.16(1) and in applying legal standards on the issue of

causation.

The district court affirmed the final agency decision in part and

reversed it in part. The court concluded the agency did not violate

section 17A.16(1) and did not err in finding Ramirez-Trujillo’s condition

after September 30, 2009, was not causally related to her work injury.

However, the court also concluded the agency misinterpreted section

85.27(4). The court found Quality Egg reasonably believed Ramirez-

Trujillo had recovered from the work injury and would not seek further

care for that injury after September 30, 2009. It also found Quality Egg

did not receive notice Ramirez-Trujillo was seeking further care after that

date for conditions related to the work injury. The court therefore

concluded Quality Egg was not liable for the expenses Ramirez-Trujillo

incurred after September 30.

Ramirez-Trujillo appealed the district court judgment. We

transferred the case to the court of appeals. The court of appeals

affirmed the portion of the district court judgment affirming a portion of

the final agency decision. However, the court of appeals concluded the

district court erroneously interpreted section 85.27(4). Accordingly, the

court of appeals reversed the portion of the district court judgment

reversing the agency’s determination that Quality Egg was liable to
 11

Ramirez-Trujillo for the expenses she incurred from May 2010 through

April 2011.

Both parties sought further review.

II. Scope of Review.

When this court grants an application for further review, we retain

discretion to review all the issues raised on appeal or in the application

for further review, or only a portion thereof. Gits Mfg. Co. v. Frank, 855

N.W.2d 195, 197 (Iowa 2014). In exercising this discretion, we choose to

review only the issue concerning the proper interpretation of Iowa Code

section 85.27(4). Accordingly, the court of appeals decision will stand as

the final decision to the extent it affirmed the district court judgment

affirming portions of the final decision of the workers’ compensation

commissioner.

The standards set forth in Iowa Code chapter 17A govern judicial

review of final decisions by the workers’ compensation commissioner.

Westling v. Hormel Foods Corp., 810 N.W.2d 247, 251 (Iowa 2012); see

Iowa Code § 17A.1(2). When the legislature has clearly vested authority

to interpret statutory language in an agency, we will defer to an agency

interpretation of that language. Renda v. Iowa Civil Rights Comm’n, 784

N.W.2d 8, 10–15 (Iowa 2010). Thus, when the legislature has clearly

vested the agency with interpretive authority, we will reverse an agency

decision only when its interpretation of statutory language is “irrational,

illogical, or wholly unjustifiable.” Coffey v. Mid Seven Transp. Co., 831

N.W.2d 81, 88 (Iowa 2013) (quoting NextEra Energy Res. LLC v. Iowa

Utils. Bd., 815 N.W.2d 30, 37 (Iowa 2012)); see Iowa Code § 17A.19(10)(l),

(11)(c). If the legislature did not clearly vest the agency with interpretive

authority, however, we review questions of statutory interpretation for
 12

correction of errors at law. Westling, 810 N.W.2d at 251; see Iowa Code

§ 17A.19(10)(c), (11)(b).

In determining whether the legislature has clearly vested

interpretive authority in the workers’ compensation commissioner, we

consider the nature of the statutory language the agency has construed.

See Burton v. Hilltop Care Ctr., 813 N.W.2d 250, 256–57 (Iowa 2012).

When the legislature has not explicitly granted interpretive authority, we

must examine “the phrases or statutory provisions to be interpreted,

their context, the purpose of the statute, and other practical

considerations to determine whether the legislature intended to give

interpretive authority to an agency.” Clay County v. Pub. Emp’t Relations

Bd., 784 N.W.2d 1, 4 (Iowa 2010) (quoting Renda, 784 N.W.2d at 11–12).

We are more likely to conclude the legislature clearly vested

interpretive power in an agency when the agency necessarily must

interpret the statutory language at issue in carrying out its duties and no

relevant statutory definition applies. Renda, 784 N.W.2d at 12, 14. In

addition, when the statutory language at issue is a substantive term

within the special expertise of an agency, we generally conclude the

legislature has vested the agency with authority to interpret it. See

NextEra Energy, 815 N.W.2d at 37. Ultimately, however, we will defer to

an agency interpretation only when we are firmly convinced “the

legislature actually intended (or would have intended had it thought

about the question) to delegate to the agency interpretive power with the

binding force of law.” Renda, 784 N.W.2d at 14 (quoting Arthur E.

Bonfield, Amendments to Iowa Administrative Procedure Act, Report on

Selected Provisions to Iowa State Bar Association and Iowa State

Government 63 (1998)).
 13

We have never before interpreted the statutory language at issue in

this appeal, though we have previously interpreted statutory language in

the same subsection of the Code. See, e.g., Bell Bros. Heating & Air

Conditioning v. Gwinn, 779 N.W.2d 193, 202–08 (Iowa 2010). Therefore,

we begin our analysis by determining whether the legislature clearly

vested the workers’ compensation commissioner with authority to

interpret the statutory language at issue. See, e.g., Gartner v. Iowa Dep’t

of Pub. Health, 830 N.W.2d 335, 343 (Iowa 2013).

Iowa Code section 85.27(4) affords an employer who does not

contest the compensability of a workplace injury a qualified statutory

right to control the medical care provided to an injured employee. R.R.

Donnelly & Sons v. Barnett, 670 N.W.2d 190, 195, 197 (Iowa 2003). It

provides in relevant part,

For purposes of this section, the employer is obliged to
furnish reasonable services and supplies to treat an injured
employee, and has the right to choose the care. If the
employer chooses the care, the employer shall hold the
employee harmless for the cost of care until the employer
notifies the employee that the employer is no longer
authorizing all or any part of the care and the reason for the
change in authorization.

Iowa Code § 85.27(4) (emphasis added).
The legislature has not expressly vested the workers’ compensation

commissioner with authority to interpret the workers’ compensation

statutes in chapter 85. The fact the legislature has granted the

commissioner authority to adopt and enforce rules necessary to the

implementation of chapter 85 does not itself indicate the legislature has

clearly vested the commissioner with authority to interpret it. See

Roberts Dairy v. Billick, 861 N.W.2d 814, 817 (Iowa 2015).

Section 85.27(4) constitutes a bread-and-butter provision of the

workers’ compensation statute regularly administered by the
 14

commissioner. The fact that an agency necessarily must interpret

statutory language in carrying out its duties provides a potential basis

for concluding the legislature clearly vested interpretive authority

therein. Renda, 784 N.W.2d at 12, 14. However, we have previously

declined to conclude the legislature clearly vested interpretive authority

in the workers’ compensation commissioner on this basis standing alone.

See Iowa Ins. Inst. v. Core Grp. of Iowa Ass’n for Justice, 867 N.W.2d 58,

65, 77 (Iowa 2015). In fact, we have declined to defer to the

commissioner’s interpretations of various provisions of chapter 85 in

recent years. Id. at 65. Moreover, section 85.27(4) contains no

substantive terms uniquely within the interpretive expertise of the

workers’ compensation commissioner.

On balance, we are not firmly convinced the legislature intended to

delegate authority to interpret section 85.27(4) to the workers’

compensation commissioner. See Renda, 784 N.W.2d at 14.

Accordingly, we will not defer to the commissioner’s interpretation of

section 85.27(4) and will substitute our own judgment for that of the

commissioner should we conclude the commissioner’s interpretation

rests on an error at law. See Iowa Code § 17A.19(11)(b); Renda, 784

N.W.2d at 14–15.

III. Analysis and Discussion.

When interpreting the statutory provisions contained in chapter 85

of the Iowa Code, our goal is to determine and effectuate the legislature’s

intent. United Fire & Cas. Co. v. St. Paul Fire & Marine Ins. Co., 677

N.W.2d 755, 759 (Iowa 2004). To determine legislative intent, we look to

the language chosen by the legislature and not what the legislature

might have said. Schadendorf v. Snap-On Tools Corp., 757 N.W.2d 330,

337 (Iowa 2008). Absent a statutory definition, we consider statutory
 15

terms in the context in which they appear and give each its ordinary and

common meaning. Rojas v. Pine Ridge Farms, L.L.C., 779 N.W.2d 223,

235 (Iowa 2010). When reasonable persons could disagree as to what a

statute means, the meaning of the statute is ambiguous. Holstein Elec.

v. Breyfogle, 756 N.W.2d 812, 815 (Iowa 2008). Ambiguity may arise due

to uncertainty concerning the meaning of particular words or upon

examination of all the statute’s provisions together in context. Id.

When the meaning of the statute is ambiguous, we may consider

rules of statutory construction in our interpretive analysis. Id. We

assess the statute in its entirety rather than isolated words or phrases to

ensure our interpretation is harmonious with the statute as a whole.

Schadendorf, 757 N.W.2d at 337. Because we presume the legislature

included every part of the statute for a purpose, we avoid construing a

statutory provision in a manner that would make any portion thereof

redundant or irrelevant. Rojas, 779 N.W.2d at 231; see Iowa Code

§ 4.4(2). We also avoid construing statutory provisions in a manner that

will lead to absurd results. Iowa Ins. Inst., 867 N.W.2d at 75; see Iowa

Code §§ 4.4(3), .6(5).

The primary purpose of the workers’ compensation statute

contained in chapter 85 is to benefit the worker. Griffin Pipe Prods. Co. v.

Guarino, 663 N.W.2d 862, 865 (Iowa 2003). To this end, chapter 85

encourages employers to compensate employees who receive workplace

injuries promptly and provides a forum for efficient resolution of

workplace-injury claims with minimal litigation. See Des Moines Area

Reg’l Transit Auth. v. Young, 867 N.W.2d 839, 847 (Iowa 2015); Bell

Bros., 779 N.W.2d at 202; Flint v. City of Eldon, 191 Iowa 845, 847, 183

N.W. 344, 345 (1921).
 16

In enacting the right-to-choose provision in section 85.27(4), our

legislature sought to balance the interests of injured employees against

the competing interests of their employers. Bell Bros., 779 N.W.2d at

202, 207; IBP, Inc. v. Harker, 633 N.W.2d 322, 326–27 (Iowa 2001). The

statute imposes an affirmative duty on employers who concede the

compensability of workplace injuries to furnish care to injured

employees. Bell Bros., 779 N.W.2d at 202. However, it also empowers

employers who fulfill this obligation “to substitute their judgment for that

of their injured employees on the important question of which medical

professionals are best suited to diagnose and treat work-related injuries.”

Baker v. Bridgestone, 872 N.W.2d 672, 678 (Iowa 2015); see R.R.

Donnelly, 670 N.W.2d at 195. In other words, the statute grants

employers a limited right to choose who provides the care to an injured

employee—a right that is modified by several statutory protections

afforded to employees. Bell Bros., 779 N.W.2d at 202–04.

Because our legislature sought to balance the interests of

employers and the interests of injured employees in enacting section

85.27(4), the right of employers to control care is not absolute. See

Baker, 872 N.W.2d at 678 n.3. Rather, an employer’s right to control

care is a limited or qualified right. R.R. Donnelly, 670 N.W.2d at 195,

197; W. Side Transp. v. Cordell, 601 N.W.2d 691, 693 (Iowa 1999); see

Bell Bros., 779 N.W.2d at 203–04. Thus, although the statute promotes

the prompt resolution of claims without litigation, it also anticipates that

workplace injuries can lead to disputes between employers and injured

employees. R.R. Donnelly, 670 N.W.2d at 195; see Bell Bros., 779 N.W.2d

at 204.

At issue in this appeal is the second sentence of section 85.27(4),

which provides,
 17
If the employer chooses the care, the employer shall hold the
employee harmless for the cost of care until the employer
notifies the employee that the employer is no longer
authorizing all or any part of the care and the reason for the
change in authorization.

We must determine how the legislature intended this sentence to modify

the right of employers to choose care for injured employees.

The first half of the sentence provides an employer who chooses

the care an injured employee receives “shall hold the employee harmless

for the cost of care.” When the term “shall” appears in a statute, it

generally connotes the imposition of a mandatory duty. In re Marriage of

Thatcher, 864 N.W.2d 533, 539 (Iowa 2015); In re Det. of Fowler, 784

N.W.2d 184, 187 (Iowa 2010). Moreover, rules of statutory construction

set forth in the Iowa Code specify that in statutes enacted after July 1,

1971, the word “shall” imposes a duty unless otherwise specified by the

legislature. 5 Iowa Code § 4.1(30)(a). Absent any ambiguity in a statutory

definition, we are obligated to apply the statutory definition the

legislature adopted to explain a statutory term. Sherwin-Williams Co. v.

Iowa Dep’t of Revenue, 789 N.W.2d 417, 425 (Iowa 2010). Accordingly,

we interpret the plain language of section 85.27(4) to obligate employers

to hold employees harmless for authorized medical expenses.

The remainder of the sentence clarifies the scope of this obligation.

Namely, it provides an employer who chooses care for an injured

employee has a corresponding duty to “hold the employee harmless for

the cost of the care until the employer notifies the employee that the

5The legislature enacted the language in section 85.27(4) granting employers a
right to choose care in 1976. 1976 Iowa Acts ch. 1084, § 3 (codified in relevant part at
Iowa Code § 85.27 (1977)); Bell Bros., 779 N.W.2d at 202 n.1. The legislature enacted
the second sentence of section 85.27(4) in 2004. See 2004 Iowa Acts 1st Extraordinary
Sess. ch. 1001, § 9 (codified at Iowa Code § 85.27(4) (2005)).
 18

employer is no longer authorizing all or any part of the care and the

reason for the change in authorization.” Iowa Code § 85.27(4). The

ordinary meaning of the word “until” is “up to the time that.” Webster’s

Third New International Dictionary 2513 (unabr. ed. 2002). Thus, section

85.27(4) plainly indicates an employer who authorizes care is responsible

for the cost of the care up to the time when the employer notifies the

employee it is no longer authorizing care.

Because section 85.27(4) obligates an employer to notify an

employee when it is no longer authorizing care, it also obligates an

employer to determine when it no longer wishes to authorize care. With

the power to choose the care comes the responsibility to monitor the care

for the purpose of determining when further care will no longer be

authorized. 6 An employer can easily reconsider whether it wishes to

authorize further care when an authorized medical provider indicates an

employee requires no further care for a workplace injury or when the

employer authorizes a new provider to take over an employee’s care.

Therefore, the employer’s statutory burden to monitor an injured

employee’s care is not an onerous one.

Section 85.27(4) balances this minimal burden with a significant
corresponding benefit—a means of extinguishing the employer’s ongoing

obligation to pay for medical expenses following its acknowledgment of

compensability and exercise of the right to choose care. Interpreting

6Though we conclude deference to the agency’s interpretation is not appropriate,
we note the commissioner previously reached the same conclusion in interpreting
section 85.27(4). See, e.g., Warner v. Alpha’s, Iowa Workers’ Comp. Comm’n No.
1269904, 2002 WL 32125384, at *6 (Sept. 9, 2002) (“An employer’s act of directing the
care and the claimant’s compliance with the employer’s directives binds defendants to
pay the cost of the care that it chose. Employers are under an obligation to monitor the
care they authorize and must pay for authorized care until the time they inform the
employee that they are withdrawing authorization.” (Citation omitted.)).
 19

section 85.27(4) to reward an employer who monitors the care it

authorizes and communicates to the employee when it is no longer

authorizing care is consistent with our prior recognition that the

legislature sought to balance the interests of employees and employers in

enacting section 85.27(4). Bell Bros., 779 N.W.2d at 202, 207; IBP, 633

N.W.2d at 326–27.

On the one hand, section 85.27(4) protects the right of employers

to choose care in various ways. Once an employer’s right to control

medical care attaches under section 85.27(4), “it remains with the

employer under the statute until the employer denies the injury is work-

related, withdraws authorization of the care, or until the commissioner

orders alternative care.” Bell Bros., 779 N.W.2d at 207. An employer’s

denial of compensability leads to the loss of its right to choose care only

when it denies the claimed injury arose in the course and scope of

employment. Id. Thus, when an employer acknowledges the injury an

employee suffered is compensable, the employer does not forfeit its right

to choose care just because it disagrees with the employee as to the

nature or extent of the disability caused by the workplace injury. Id.

Even after a dispute arises concerning the compensability of a portion of

the injured employee’s ongoing care, the employer is entitled to control

ongoing care to treat injuries with respect to which it does not contest

compensability. See id. After an employer relieves an employee of the

burden of proving causation by acknowledging compensability and

authorizing care, the employer may reinstate that burden to the extent it

believes compensability is in doubt. See id. at 207–08.

On the other hand, section 85.27(4) safeguards the ability of

employees to make decisions regarding the course of the care they

receive. Nothing in the statute prevents an employee from obtaining
 20

unauthorized care. See id. at 205; see also R.R. Donnelly, 670 N.W.2d at

197. In addition, nothing in the statute prevents an employee from

obtaining reimbursement for expenses incurred in seeking unauthorized

care upon an adjudication of compensability. 7 Bell Bros., 779 N.W.2d at

206. Rather, an employee generally may recover medical expenses

incurred in seeking unauthorized care upon proving by a preponderance

of the evidence the care was reasonable and beneficial under the totality

of the circumstances. Id. Moreover, when the employee believes the

employer has not offered care promptly or has offered care that is unduly

inconvenient or not reasonably suited to treat the injury sustained, the

employee may apply with the workers’ compensation commissioner for

approval to seek alternate care. 8 R.R. Donnelly, 670 N.W.2d at 196; W.

Side Transp., 601 N.W.2d at 693. Thus, the commissioner retains

authority to order the employer to pay for care chosen by the employee.

W. Side Transp., 601 N.W.2d at 693. Additionally, the statute instructs

7An employer may successfully assert a lack-of-authorization defense when an
employee seeks reimbursement for unauthorized care obtained after the workers’
compensation commissioner denies the employee’s application for alternate care on the
merits. Bell Bros., 779 N.W.2d at 205; R.R. Donnelly, 670 N.W.2d at 197–98.
8Notably, the commissioner has adopted two regulations that bolster our
conclusion an employee is entitled to be informed when an employer decides it will no
longer authorize care. First, the commissioner will not hear the parties on an
application for alternate care until the employee communicates the basis of his or her
dissatisfaction to the employer. See Iowa Admin. Code. r. 876—4.48(4), (8); see also
Iowa Code § 85.27(4) (stating an employee with reason to be dissatisfied with the care
offered “should communicate the basis of such dissatisfaction to the employer, in
writing if requested”). As a result, the employee cannot receive an order directing the
employer to pay for alternate care until he or she knows that care will be denied by the
employer. Second, the commissioner will dismiss an application for alternate care if the
employer denies the condition for which care is sought is compensable. R.R. Donnelly,
670 N.W.2d at 196, 197; see Iowa Admin. Code r. 876—4.48(7). Thus, an employee
needs to know whether to apply for alternate care or seek adjudication on
compensability in order to avoid delayed reimbursement for expenses incurred in
seeking care.
 21

the commissioner to issue decisions on applications for alternate care

within ten to fourteen days of their receipt. Iowa Code § 85.27(4).

As the foregoing overview makes clear, section 85.27(4) does not

require employees to prove medical causation in order to establish

employer liability for authorized medical expenses. 9 Rather, under

section 85.27(4), an employer obtains the right to choose care only by

conceding the compensability of the claimed injury. Bell Bros., 779

N.W.2d at 207. That means before the employer chooses care and

authorizes it, the employer must concede the claimed injury arose in the

course and scope of employment. See Lakeside Casino v. Blue, 743

N.W.2d 169, 173 (Iowa 2007) (explaining that a compensable injury

requires a connection between the injury and employment, which “is

established by showing the injury arose out of and in the course of the

worker’s employment”). To interpret section 85.27(4) to require an

employee seeking payment of authorized medical expenses to prove

compensability after the employer has conceded compensibility would

upset the delicate balance of employer and employee protections the

legislature sought to achieve in enacting section 85.27(4). To do so

would undermine the concept of authorized care and subject employees

to retroactive liability for care they did not choose. 10 See Iowa Ins. Inst.,

9We note this conclusion is consistent with prior interpretations of section
85.27(4) by the commissioner. See Warner, 2002 WL 32125384, at *6 (“When an
employer chooses the care it must pay for the care it chose, even if it later learns that it
might not have been liable for that care if it had not directed the care.”).
10We have never considered the question of whether section 85.27(4) requires an

employee to prove compensability of the condition for which treatment was sought to
establish an entitlement to reimbursement of authorized medical expenses. We once
reinstated a ruling by the commissioner disallowing medical expenses because “the
claimant had failed to present sufficient evidence to prove a causal connection between
the conditions which were the subject of the treatment and the claimant’s work-related
injury.” Auxier v. Woodward State Hosp.-Sch., 266 N.W.2d 139, 144 (Iowa 1978).
However, we did so because the trial court erroneously determined the claimant had
 22

867 N.W.2d at 75 (“We have long recognized that statutes should not be

interpreted in a manner that leads to absurd results.”); see also Iowa

Code § 4.4(3) (stating it is presumed the legislature intends statutes to

effect just and reasonable results); id. § 4.6(5) (indicating a court may

consider consequences in construing an ambiguous statute).

Conversely, it is apparent from the language of the statute the

employer generally must choose the care as a precondition to being

responsible for its costs. The operative phrase is “chooses the care,” not

“has chosen the same provider at some time in the past.” Furthermore,

the second sentence of subsection (4) must be read together with the first

sentence, which states, “For purposes of this section, the employer . . .

has the right to choose the care.” Iowa Code § 85.27(4). Thus, the

choice of care referenced in the second sentence of section 85.27(4) is a

choice for purposes of the entire section—namely, section 85.27. And

the overall purpose of the section is the treatment of “injuries

compensable under [chapter 85].” Id. § 85.27(1). This further highlights

that employer liability in section 85.27(4) is premised upon an employer’s

_____________________
established a causal connection between the conditions treated and the workplace
injury as a matter of law. See id. In that case, we did not consider whether section
85.27(4) requires reimbursement of authorized medical expenses not causally
connected to a workplace injury. See id. Because that question was not actually
presented and decided in Auxier, we do not treat that case as controlling.
The commissioner’s interpretation of the statute on this question is not entitled
to deference. See Iowa Code § 17A.19(11)(b). Nonetheless, we note the commissioner
no longer interprets section 85.27(4) to require an employee to demonstrate authorized
medical expenses were causally connected to the workplace injury to establish an
entitlement to reimbursement. See, e.g., Norton v. Leonard Express, Inc., Iowa Workers’
Comp. Comm’n No. 5027578, 2013 WL 482726, at *2 (Jan. 23, 2013) (“Employer[s]
must pay for the care they authorize, even if that care was later on determined
unrelated to the work injury.”); Lenzini v. Des Moines Area Cmty. Coll., Iowa Workers’
Comp. Comm’n No. 5002823, 2003 WL 22513678, at *5 (Oct. 29, 2003) (“When an
employer chooses the care it must pay for the care it chose, even if it later learns that it
might not have been liable for that care if it had not directed the care.”).
 23

choice of care for a particular injury. Under the plain statutory language

of section 85.27(4), it is not enough that the employee happened to show

up for treatment at a health care provider to which the employer had

referred the employee in the past.

Similarly, interpreting section 85.27(4) to impose liability on

employers for any medical care an employee receives from an authorized

medical provider would lead to absurd results. As we recently stated:

We have long recognized that statutes should not be
interpreted in a manner that leads to absurd results. In
order to apply this well-established rule, we sometimes
consider fact patterns other than the one before the court to
determine if a particular statutory interpretation would have
untoward consequences. That is part of the judicial
function—to consider alternative statutory interpretations
and see where those alternatives logically lead.

Iowa Ins. Inst., 867 N.W.2d at 75–76 (citations omitted); see Iowa Code

§§ 4.4(3), .6(5). Undoubtedly, the legislature did not intend an employer

who acknowledged the compensability of a foot injury to be liable for

expenses the employee incurred after getting the flu merely because the
employee sought care at an authorized medical center.

Interpreting section 85.27(4) to require such a result would

discourage employers from authorizing care for fear of incurring liability

for conditions clearly unrelated to the workplace. For example,

employers would be discouraged from authorizing care to a medical

facility as opposed to an individual specialist in order to avoid liability for

treatment the employee receives for unrelated conditions. It is unlikely

the legislature intended that result, as employees retain the ability to

exercise some degree of choice concerning who will treat their injuries

when their employers authorize care from medical facilities rather than

individual medical providers.
 24

To illustrate, we note the provider at issue here is the Wright

Medical Center located in Clarion, Iowa, the county seat of Wright

County. The record does not indicate whether there are any other health

care facilities or individual health care providers in Wright County, but

clearly Wright Medical Center offers a wide array of services. From

reviewing the medical records, we know it has an emergency room, a

rehabilitation department, a family practice clinic, a specialty clinic,

hospital beds, and facilities for surgeries and births. Undoubtedly,

Quality Egg did not intend to bind itself to pay for any care Ramirez-

Trujillo might receive at Wright Medical Center merely by authorizing her

to seek care for her work injury at that facility.

Consequently, we conclude section 85.27(4) limits employer

liability for authorized care to expenses incurred seeking care related to

the medical condition or conditions for which the employee sought care

in the aftermath of a workplace injury and upon which the employee’s

claim for workers’ compensation benefits is based. 11

Here, Quality Egg produced no evidence to suggest Ramirez-

Trujillo did not incur the expenses she claimed seeking treatment for a

back condition. In fact, Quality Egg conceded the medical expenses
Ramirez-Trujillo incurred were at least causally connected to the medical

condition upon which her claim of injury was based. Accordingly, under

the foregoing analysis, it remains unclear whether Quality Egg was

11We previously determined section 85.27(4) implicitly limits employer liability
for unauthorized care. See Bell Bros., 779 N.W.2d at 206 (indicating an employee may
generally recover medical expenses incurred in seeking unauthorized care upon proving
by a preponderance of the evidence that such care was reasonable and beneficial under
the totality of the circumstances). Because it would be unfair to impose the cost of care
the employer chose on the employee merely because it was not reasonable or turned out
not to be beneficial, we do not interpret section 85.27(4) to implicitly limit employer
liability for authorized care in precisely the same manner.
 25

required to hold Ramirez-Trujillo harmless for care she received from

May 2010 through April 2011. This is because Quality Egg produced no

evidence to show it notified Ramirez-Trujillo that it was not authorizing

further care.

In essence, Quality Egg disputes the care Ramirez-Trujillo received

from May 2010 through April 2011 was authorized care, even though it

concedes it initially authorized her to seek care in the aftermath of her

workplace injury. 12 Thus, Quality Egg argues a second limiting principle

constrains employer liability for authorized care under section 85.27(4).

Specifically, Quality Egg suggests an employer need only notify the

employee it is no longer authorizing care to relieve itself of liability when

a reasonable employer would know the injured worker continues to seek

care. Quality Egg thus argues the statute imposes an obligation on

employees to make sure care authorizations are still in force before

seeking further care.

We disagree. Section 85.27(4) contains no language to suggest the

legislature intended to obligate employees to make sure care

authorizations remain in force before accepting care. Rather, the plain

language of the statute obligates employers who authorize care for

workplace injuries. Namely, an employer who authorizes care must pay

for the cost of care until the employer notifies the employee it is no longer

authorizing care. For purposes of determining whether an employer is

liable for the cost of care an employee received after the employer

authorized care for a workplace injury and failed to notify the employee it

12The statute requires an employer to hold an employee harmless for the cost of
authorized care until it notifies the employee it is no longer authorizing care, but it does
not indicate that care remains authorized until the employer notifies the employee it is
no longer authorizing care. See Iowa Code § 85.27(4).
 26

was not authorizing further care, it is irrelevant that the employer did

not intend its authorization to remain in effect. 13

Importantly, nothing in the language of section 85.27(4) suggests

employees have a duty to investigate or a duty to inquire as to whether

an authorization remains in effect before seeking care. To conclude the

statute imposes such a duty on employees when the language of the

statute clearly imposes a duty on employers would be inconsistent with

our longstanding practice of construing chapter 85 liberally in favor of

employees. See Griffin Pipe Prods., 663 N.W.2d at 865. The legislature

did not intend employees to fear they might have to pay for care they did

not choose merely because they accepted it. Interpreting section

85.27(4) to impose a continuing obligation on employees to make sure

the employer still authorizes care before accepting it would turn the

statute on its head.

However, that does not mean the statute permits an employee to

take advantage of an employer by seeking compensation after the fact for

care the employee knew or should have known was not within the scope

of the employer’s prior authorization. Section 85.27(4) seeks to protect

the employer who acknowledges an injury arose in the course and scope

of employment and honors its obligation to “furnish reasonable services

and supplies to treat an injured employee.” Iowa Code § 85.27(4). We

simply do not believe section 85.27(4) requires an employer to notify an

employee it is no longer authorizing care when the employee knows or

reasonably should know the care sought is for a condition unrelated to a

compensable workplace injury or the prior authorization is no longer in

13We agree with the commissioner an employer “cannot revoke authorization
retroactively to avoid liability for expenses previously incurred.” Warner, 2002
WL 32125384, at *6.
 27

effect. See Iowa Ins. Inst., 867 N.W.2d at 75–76; see also Iowa Code

§§ 4.4(3), .6(5).

Accordingly, we conclude an employer may establish it is not liable

for the cost of care an employee received from an authorized medical

provider if it proves by a preponderance of the evidence the employee

knew or reasonably should have known either that the care was

unrelated to the medical condition or conditions upon which the

employee’s claim for workers’ compensation benefits is based or that the

employer no longer authorized the care the employee received at the time

the employee received it. With respect to the latter alternative, the

determinative question is whether the totality of the circumstances

indicates the employee knew or should have known the employer no

longer authorized the care the employee received, not whether the

employee believed the care was compensable when the employee received

it. An employer may avoid liability by showing the employer gave the

employee actual notice of a change in authorization as required by

section 85.27(4). 14 Alternatively, the employer may prove the employee

had knowledge of facts and circumstances that would have led a

reasonable employee to conclude the employer was no longer authorizing
care for the claimed injury. 15

14In
other words, the employer may disprove liability by showing it notified the
employee that the employer was “no longer authorizing all or any part of the care and
the reason for the change in authorization.” Iowa Code § 85.27(4).
15Of course, if it turns out the care was related to a workplace injury, the

employer must pay for care regardless of what the employee knew or should have
known at the time unless the employer proves it notified the employee of a change in
authorization. Employer liability for authorized care does not turn on the beliefs of the
employee. Warner, 2002 WL 32125384, at *6 (“It is unreasonable to expect a claimant
to have the medical expertise necessary to decide whether to accept the care directed by
the employer upon the chance the employer might later deny liability for the condition
being treated. Lay persons, such as claimant, are not competent to testify on the issue
 28

We caution that the outcome under this test does not rely on the

concepts of constructive knowledge or constructive notice because

section 85.27(4) imposes no duty of knowledge on employees. See

Knowledge, Black’s Law Dictionary (10th ed. 2014) (defining

“constructive knowledge”); Notice, Black’s Law Dictionary (defining

“constructive notice”). Likewise, it does not rely on the concepts of

implied knowledge, implied notice, or inquiry notice because section

85.27(4) imposes no duty of inquiry on employees. See Knowledge,

Black’s Law Dictionary (defining “implied actual knowledge”); Notice,

Black’s Law Dictionary (defining “implied notice” and “inquiry notice”).

In addition, we caution that the test we now adopt to determine

employer liability for authorized medical expenses under section 85.27(4)

does not turn on the subjective beliefs an employee holds with respect to

compensability or medical causation. 16 Rather, it is an objective test.

This distinction is important because employees are ordinarily

laypersons without the expertise necessary to make accurate

determinations regarding medical causation. See Bradshaw v. Iowa

Methodist Hosp., 251 Iowa 375, 383, 101 N.W.2d 167, 171 (1960). We

long ago recognized that medical causation “is a question with respect to
which only a medical expert can express an intelligent opinion.” Id.

Thus, an employee’s subjective beliefs concerning the cause of a medical

condition or the compensability of expenses incurred are ordinarily

_____________________
of medical causation because they lack competency to do so. They are no more
competent when they are receiving the care than when testifying.”).
16This conclusion arguably follows from the fact that employer liability for
authorized care does not turn on the compensability of the injury. As the commissioner
has recognized, it would be unreasonable for employer liability to turn on the beliefs of
the employee. Warner, 2002 WL 32125384, at *6.
 29

incompetent to prove or disprove compensability or medical causation.17

See Cedar Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa

2011); Bradshaw, 251 Iowa at 383, 101 N.W.2d at 171. Moreover, in the

context of determining whether an employer is liable for authorized care,

compensability and medical causation are not even at issue in a claim for

reimbursement. 18

We conclude an employer may prove it is not liable for the cost of

care an employee received from an authorized medical provider despite

the employer’s failure to give the notice section 85.27(4) requires under

limited circumstances. However, when an employer seeks to avoid

liability for care an employee received from an authorized provider and

cannot prove it notified an employee it was not authorizing further care

from that provider, the employer bears the burden of proving by a

preponderance of the evidence the employee knew or reasonably should

have known either that the care the employee received was unrelated to

the medical condition or conditions upon which the employee’s claim for

17It is irrelevant whether the employee’s subjective belief was based on
statements made by a medical professional. As the evidence before the hearing deputy
in this case demonstrates and the commissioner surely knows, medical professionals
often arrive at conflicting conclusions regarding medical causation. See Warner, 2002
WL 32125384, at *6 (“Medical experts commonly disagree as to the cause of a condition
and an injured claimant cannot be held to know when to accept and when to reject the
care the employer’s physicians offer.”). Generally, an expert opinion regarding medical
causation is not determinative in a claim for workers’ compensation benefits. See
Cedar Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa 2011). Rather, it is
within the province of the commissioner to accept or reject an expert opinion. Id.
18Employee statements indicating an employee subjectively believed the
employer was no longer authorizing further care are relevant to determining whether
the employee knew the employer was no longer authorizing care he or she received.
However, because the overarching purpose of the workers’ compensation statute is to
protect workers, ambiguous statements should be construed as statements concerning
causation or compensability and not as statements concerning the effectiveness of a
prior authorization for care unless circumstances clearly suggest the latter
interpretation is more appropriate. Employees are generally lay persons not familiar
with the legal standards applied in assessing their workers’ compensation claims.
 30

workers’ compensation benefits is based or that the employer no longer

authorized the care the employee received at the time the employee

received it.

In determining whether the employer has proven by a

preponderance of the evidence the employee knew or reasonably should

have known it no longer authorized the care the employee received at the

time the employee received it, the commissioner shall consider the

following facts and circumstances: (1) the method in which the employer

communicated to the employee that care was authorized throughout the

period during which the employer concedes care was authorized; (2) the

actual communications between the employer and employee throughout

that period and thereafter concerning the injury, the care, and the costs

of the care; (3) any communications between the employee and medical

providers; (4) how much time passed between the date the employer

authorized care and the date the employee sought the disputed care; (5)

the nature of the injury for which the employer authorized care; (6) the

nature of the care the employee received, including the overall course of

the care and the frequency with which the employee sought or received

care throughout the period during which the employer concedes care was

authorized and thereafter; and (7) any other matters shown by the

evidence to bear on what the employee knew or did not know with

respect to the question of whether the employer authorized the care

sought when the employee received it. If the employer proves the

employee knew or reasonably should have known the employer did not

authorize further care when he or she received care from a previously

authorized provider, the employer is not liable for the cost of the

unauthorized care.
 31

Our resolution of the statutory interpretation issue in this case

protects the interests of both employers and employees and honors the

legislature’s intent in enacting and amending section 85.27(4). By

construing section 85.27(4) to avoid potential due process problems that

could arise when an employee is denied reimbursement of medical

expenses without notice from the employer, our interpretation of section

85.27(4) is also consistent with the principle of constitutional avoidance.

See Auxier v. Woodward State Hosp.-Sch., 266 N.W.2d 139, 142 (Iowa

1978) (concluding a claimant’s interest in workers’ compensation

benefits constitutes a property right an employer cannot terminate

without prior notice).

The commissioner made no findings of fact that would permit us to

assess whether Ramirez-Trujillo knew or reasonably should have known

Quality Egg no longer authorized further care by Wright Medical Center

for her back injury when she sought and received care from May 2010

through April 2011. Therefore, remand is appropriate because we are

unable to determine from this record whether Quality Egg is liable for the

medical expenses Ramirez-Trujillo incurred during this period under our

interpretation of section 85.27(4). On remand, the commissioner should

find the facts necessary to determine whether Quality Egg proved by a

preponderance of the evidence that Ramirez-Trujillo knew or reasonably

should have known Quality Egg no longer authorized further care for her

back injury when she incurred the disputed medical expenses. If the

commissioner allows further testimony, the commissioner may properly

limit that testimony to matters as to which each witness has not

previously testified. Winnebago Indus. v. Smith, 548 N.W.2d 582, 584

(Iowa 1996).
 32

IV. Disposition.

We affirm in part the decisions of the court of appeals and the

district court. The court of appeals decision stands as the final decision

of this court to the extent it affirmed the district court decision affirming

in part the final agency decision. We reverse in part the district court

judgment and remand the case to the district court with instructions to

remand the case to the commissioner for further proceedings consistent

with this opinion.

DECISION OF COURT OF APPEALS AFFIRMED IN PART AND

VACATED IN PART; DISTRICT COURT JUDGMENT AFFIRMED IN

PART AND REVERSED IN PART; CASE REMANDED WITH

INSTRUCTIONS.

All justices concur except Hecht, J., who dissents.
 33
#14–0640, Ramirez-Trujillo v. Quality Egg
HECHT, Justice (dissenting).

Although the standard devised by the majority for determining

whether an employer authorized medical care could have been adopted

by the legislature, I do not believe it was. Accordingly, I respectfully

dissent.

In relevant part, section 85.27(4) provides:

For purposes of this section, the employer is obliged to
furnish reasonable services and supplies to treat an injured
employee, and has the right to choose the care. If the
employer chooses the care, the employer shall hold the
employee harmless for the cost of care until the employer
notifies the employee that the employer is no longer
authorizing all or any part of the care and the reason for the
change in authorization. An employer is not liable for the
cost of care that the employer arranges in response to a
sudden emergency if the employee’s condition, for which care
was arranged, is not related to the employment.

Iowa Code § 85.27(4) (2009) (emphasis added).

The majority concludes this statute is ambiguous. It is not. If the

“statutory language is plain and its meaning clear, ‘we do not search for

legislative intent beyond the express terms of the statute.’ ” Denison

Mun. Utils. v. Iowa Workers’ Comp. Comm’r, 857 N.W.2d 230, 235 (Iowa

2014) (quoting State Pub. Defender v. Iowa Dist. Ct., 663 N.W.2d 413,

415 (Iowa 2003)).

As the majority correctly observes, it is well established that an

employer “has the right to choose the care” for work-related injuries.

Iowa Code § 85.27(4). This right to choose the care refers to an

employer’s power to designate which provider(s) of medical care will be

authorized to treat the employee’s injury. See id. Such control comes at

a price. First, employers choosing providers of care generally concede
 34

their employees’ injuries are compensable. 19 See Bell Bros. Heating & Air

Conditioning v. Gwinn, 779 N.W.2d 193, 202 (Iowa 2010) (noting

employers receive the right to choose care “[o]nce compensability is

acknowledged”); 15 James R. Lawyer, Iowa Practice Series: Workers’

Compensation § 15:2, at 199 (2015) [hereinafter Lawyer] (“If the employer

denies the compensability of an injury under the act, it cannot . . . seek

to guide the care.”). Second, employers hold their employees harmless

for the cost of the care provided by the chosen providers. Iowa Code

§ 85.27(4); 15 Lawyer § 15:2, at 198–99.

Employers have significant power in the process of furnishing

medical services as they select who shall be authorized providers.

Employers can confer authorization of care by a provider; they can also

reasonably terminate it. Authorization lasts “until the employer notifies

the employee that the employer is no longer authorizing all or any part of

the care and the reason for the change in authorization.” Iowa Code

§ 85.27(4). The notice of a change in authorization does not conclusively

cut off the employer’s obligation to furnish medical services under

section 85.27(1); it does, however, oblige the injured employee to prove

medical causation as to any services obtained from unauthorized

providers for treatment of a work-related injury. 15 Lawyer § 15:2, at

199 (noting the employer’s obligation to provide medical services under

section 85.27 extends to unauthorized medical care that “is beneficial in

improving the worker’s condition”). The commissioner applied the clear

language of section 85.27(4) and concluded Quality Egg is obligated to

pay for medical expenses Ramirez-Trujillo incurred for treatment by the

19Compensable injuries are those arising in the course and scope of
employment. Iowa Code § 85.3(1).
 35

authorized provider after September 2009 because Quality Egg failed to

notify Ramirez-Trujillo that further treatment by that provider was not

authorized. In this instance, I believe the commissioner correctly applied

the statute.

The majority fashions a new standard for determining whether an

employer’s authorization of care can terminate notwithstanding the

employer’s failure to notify their injured employee of the termination.

The new standard is problematic because it is not found within section

85.27(4). The statute is not ambiguous, so we need not apply rules of

interpretation or develop new standards to divine its meaning. Section

85.27(4) expressly confers upon employers the right to “choose the care”

and prescribes the consequences of an employer’s choice of medical care

for the employee. Iowa Code § 85.27(4). Among the consequences is the

employer’s obligation to hold employees harmless for the cost of services

supplied by authorized providers. Id.

The legislature expressly prescribed only one safe harbor in which

the employer’s choice of care does not result in a concession of

compensability: “An employer is not liable for the cost of care that the

employer arranges in response to a sudden emergency if the employee’s

condition, for which care was arranged, is not related to the

employment.” Id. The unmistakable rationale for this safe harbor is that

in emergent scenarios, employers do not have time to assess whether the

injury or condition for which treatment is urgently needed arose out of

and in the course of employment. Notably, Quality Egg makes no claim

in this case that its authorization of the Wright Medical Center as a

provider was granted in a sudden emergency.

Section 85.27(4) expressly exempts employers from their statutory

duty to hold employees harmless from the cost of medical services
 36

provided by authorized providers if employers give their employees notice

that the authorization is terminated or changed. Id. Under the clear

meaning of the statute, the employer’s authorization of care for treatment

of a compensable injury continues until the employer gives the employee

notice of a change. The majority’s new standard announces that an

employer’s notice terminating or changing authorization is not the only

means of terminating authorization and avoiding the duty to hold the

employee harmless. Under the new standard, employers can now avoid

the consequences of choosing care—even if they fail to give the statutory

notice—by proving the employee knew or should have known the care

was beyond the scope or duration of the employer’s authorization.

The majority’s new standard allowing employers to avoid the

consequences of choosing care without giving notice as contemplated in

section 85.27(4) is problematic for several reasons. First, it is

incompatible with the clear language of the statute indicating a provider

is authorized until notice to the contrary is given. Second, I think the

new standard will create confusion and uncertainty among parties in

workers’ compensation cases about whether medical care is authorized.

Confusion and uncertainty will spawn more litigation—an untoward

consequence for a workers’ compensation system intended to be simple,

quick, and inexpensive. See, e.g., Baker v. Bridgestone/Firestone, 872

N.W.2d 672, 677 (Iowa 2015); Morrison v. Century Eng’g, 434 N.W.2d

874, 877 (Iowa 1989); Flint v. City of Eldon, 191 Iowa 845, 847, 183 N.W.

344, 345 (1921). In place of the former predictable bright-line rule

allocating to employers liability for medical care provided by authorized

providers for work-related injuries until the authorization is withdrawn

by notice, the majority’s new standard encourages additional fact-based

inquiries about what the employee knew about the scope and duration of
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a provider’s authorization and when she knew it. Employers will be

motivated to litigate whether injured employees knew or should have

known the care provided was for a condition outside the scope of the

employer’s authorization, or whether employees knew or should have

known the authorization had expired under the circumstances even if

the employer gave no notice of expiration as contemplated in section

85.27(4). Litigating these questions will make workers’ compensation

proceedings slower and more expensive as lawyers and fact-finders

scrutinize the often complex factual circumstances addressed in the

standard’s numerous factors. As with any multifactored standard, fact-

based outcomes will be more unpredictable than outcomes produced by

the commissioner’s bright-line rule. See United States v. Mead Corp., 533

U.S. 218, 241, 121 S. Ct. 2164, 2178, 150 L. Ed. 2d 292, 312 (2001)

(Scalia, J., dissenting) (criticizing “th’ol’ ‘totality of the circumstances’

test” because it thwarts predictability and hampers “litigants who want

to know what to expect”). With due respect, the clear language of the

statute and its bright-line allocation of responsibility for care provided by

authorized providers prior to notice of a change is far superior to (and far

simpler than) the majority’s new unwieldy standard.

I agree completely with the majority’s conclusion that employees

are not generally equipped to assess whether the condition for which

they consult an authorized provider is attributable to a work-related

injury. I am convinced this very understanding informed the legislature’s

choice of a bright-line rule allocating liability to employers for the cost of

care provided by those they choose until employers give notice of the

withdrawal or change of the provider’s authorization. Iowa Code

§ 85.27(4) (“[T]he employer shall hold the employee harmless for the cost

of care until the employer notifies the employee that the employer is no
 38

longer authorizing all or any part of the care and the reason for the

change in authorization.”).

The majority designs the new standard to remedy unfairness it

perceives in the risk that an employer might be required to pay for

medical services provided by an authorized provider for a condition

ultimately found not to have been causally connected to a compensable

injury. But this risk is one the legislature built into the system as part of

the delicate balance between the interests of injured employees and their

employers in workers’ compensation cases. Bell Bros., 779 N.W.2d at

207 (“[T]he overall approach of section 85.27(4) [is] to balance the control

given to the employer with safeguards for the employee.”); see also Baker,

872 N.W.2d at 676–77 (describing the “series of tradeoffs” inherent in the

workers’ compensation system). Employers receive the opportunity to

control the care under section 85.27(4). The price of this opportunity for

control, as I have suggested above, includes employers’ concessions of

(1) the causal connection between the employment and the injury, and

(2) medical causation—medical treatment reasonable in amount and

necessary to treat the compensable injury. See Bell Bros., 779 N.W.2d at

202.

I acknowledge the commissioner’s decision in this case presents an

instance in which an employer paid a price for its decision to control the

medical care. The commissioner’s decision held Quality Egg liable for

some medical expenses the commissioner ultimately found causally

unrelated to the compensable injury Ramirez-Trujillo sustained in

August 2009. 20 The rationale for the commissioner’s decision was based

20All of the disputed medical expenses were for treatment of Ramirez-Trujillo’s
back pain, not some part of the anatomy unaffected by the work-related injury. The
legislature’s bright-line hold harmless rule did not impose on Ramirez-Trujillo the
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on Quality Egg’s failure to give notice under section 85.27(4) that it had

terminated the care provider’s authority to treat Ramirez-Trujillo’s back.

In my view, the majority’s newly-conceived multifactored standard for

limiting the scope and duration of Quality Egg’s authorization disrupts

the balance of interests set by the legislature. The balance prescribed by

the legislature afforded Quality Egg the opportunity to terminate its

provider’s authority to provide services by giving a simple notice to

Ramirez-Trujillo. By giving such a notice, Quality Egg could have shifted

the burden of proving medical causation back to Ramirez-Trujillo. But it

failed to give the notice, and the commissioner therefore correctly ordered

that Ramirez-Trujillo be held harmless for the cost of the care.

Employers’ responsibility to hold injured employees harmless for

care provided by authorized providers absent a termination notice—a

feature of the delicate balance between the competing interests of

employers and employees—does not impose an onerous burden. After

choosing the care for injured employees, employers and their insurers

routinely and regularly monitor the care through full access to medical

records and information. 21 Armed with detailed information about their

authorized providers’ services and their employees’ responses to
treatment, employers are well-equipped to meet the responsibilities

assigned to them under section 85.27(1) and protect their interests

_____________________
burden of sorting out before seeking treatment from the authorized provider whether
the back pain she experienced after September 30, 2009, was causally related to the
2009 injury or some other unrelated activity such as scooping snow. The legislature
reasonably, in my view, concluded such complex determinations are typically beyond
the ken of lay people and are best left to medical experts. In short, the hold harmless
obligation worked quite sensibly under the circumstances presented in this case.
21The employee or claimant making a claim for benefits must release “all
information . . . concerning [their] physical or mental condition relative to the claim.”
Iowa Code § 85.27(2).
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under section 85.27(4). Because they control the care under the

statutory scheme, employers are readily able to give employees notice of

“change[s] in authorization” when the employer chooses. Iowa Code

§ 85.27(4). This means of changing employers’ authorizations of care

renders the majority’s multifactored standard completely unnecessary.

In this case, Quality Egg could easily have withdrawn Wright Medical

Center’s authority to treat Ramirez-Trujillo’s back at Quality Egg’s

expense in September 2009 when Ramirez-Trujillo was discharged from

care, or in December 2009 when she returned to the provider with

complaints arising after she shoveled snow—but it did not.

Because I believe the majority’s new standard is unsupported by

the clear language of section 85.27(4) and likely to create confusion and

spawn more litigation, I would affirm the court of appeals decision and

the commissioner’s application of the statute.