Two utilization reviewers said no. A judge who watched her limp said otherwise
A Tennessee employer used paper reviews to block a worker's knee surgery. A judge sided with the doctor who actually examined her.
On March 13, 2025, Yalonda Woods tore the meniscus in her left knee at work. Her authorized treating physician, Dr. Jonathan Shaver, recommended a total knee replacement. Her employer, Tennova Healthcare Hospice, disagreed. It argued the surgery was not medically necessary and sent the recommendation to utilization review – the process insurers and employers use to vet whether a treatment should be covered.
A review doctor, Dr. Tamara Pylawka, denied the surgery. Imaging, she said, showed only mild osteoarthritis. The Bureau's Medical Director backed her up, citing Woods's weight and the fact that she had not yet tried physical therapy.
So, Woods tried physical therapy. The notes told a different story: daily trouble climbing stairs, swelling, and pain that did not let up despite real effort. When therapy ended with no improvement, Dr. Shaver ordered the surgery again in December 2025. He now had a newer x-ray showing more joint narrowing and degenerative changes consistent with osteoarthritis.
Tennova sent it back to review. Dr. Pylawka denied it a second time, citing missing documentation of how severe the osteoarthritis was. The Medical Director agreed again, faulting the records for not describing weight-loss efforts or physical-exam findings.
This is where the ruling matters for anyone who manages workers' comp claims. Under Tennessee law, a treating physician's surgery recommendation is presumed medically necessary. The employer carries the burden to rebut that presumption. And the court does not simply defer to its reviewers – it runs a de novo review, looking at the evidence fresh.
Judge Brian K. Addington did exactly that, and the paper denials did not hold up. Neither reviewer had seen Woods's functional capacity evaluation, where a therapist watched her walk with a limp and noted increased pain throughout the test. Neither reviewer had examined her in person. The judge noted that the Medical Director never explained the weight concern – and that Dr. Shaver's records raised no weight issue at all. He also pointed out that he watched Woods limp to the witness stand himself.
The court credited the treating physician as more persuasive and found the reviewers had not rebutted the presumption. In a June 2, 2026 order, it directed Tennova to authorize the surgery. The order is interlocutory, with a status hearing set for July 27, 2026, and remains subject to appeal.
The lesson for HR and claims teams is practical. Utilization review is a screening tool, not a final word. A reviewer working only from paper – records the employer was responsible for supplying – can be outweighed by the physician who actually treated the worker once a judge takes a fresh look. If your denial strategy rests on reviewers who never see the employee, expect a court to weigh that against you.
The case is Woods v. Tennova Healthcare Hospice, decided by the Tennessee Court of Workers' Compensation Claims on June 2, 2026.
