Diagnosis Not Dispositive Whether Medical Treatment For PA Work Injury Covered

The Pennsylvania Workers’ Compensation Act sets forth that medical treatment related to a work injury is to be paid for by the workers’ comp insurance carrier (provided the treatment is reasonable and necessary).  If there is a dispute as to whether treatment is related to a work injury, a petition must be filed.  If, on the other hand, the dispute is whether treatment is reasonable and necessary, then the Utilization Review process is to be used.  Whether treatment is related to a work injury is not a factor in a Utilization Review.  A recent decision from the Commonwealth Court of Pennsylvania dealt with this distinction.

In Haslam v. Workers’ Compensation Appeal Board (London Grove Communication), the injured worker (“Claimant”), fell from a building.  He suffered fractures to his right ankle, tibia, and fibula, a left calcaneus fracture, and injuries to his neck and low back.  After some time, the indemnity aspect (wage loss part) of the work injury was settled by Compromise & Release Agreement.  The settlement documents described the work injury as “R and L Foot Fracture.”

After the settlement, the workers’ compensation insurance company filed for Utilization Review against the treating doctor, seeking a ruling of whether ongoing medical treatments, including compound creams, were reasonable and necessary.  The Utilization Review Determination found all treatment to be reasonable and necessary.

The Utilization Review Determination was appealed by the workers’ comp insurance carrier to a Workers’ Compensation Judge (WCJ).  The argument raised by the insurer was not that the treatment was not, in fact, reasonable and necessary, but, rather, that the treatment was not related to the work injury.  As noted in the Determination, the diagnosis rendered by the treating physician was Reflex Sympathetic Dystrophy (RSD), otherwise known as Complex Regional Pain Syndrome (CRPS).  Since only the “R and L Foot Fracture” was described in the settlement documents, the Claimant filed a Petition to Review, to add RSD/CRPS to the accepted work injury.

After reviewing the evidence, the WCJ found the treatment to be related to the work injury, regardless of the diagnosis rendered.  The pain being addressed by the treatment stemmed from the work injury to the feet.  As such, the WCJ denied the workers’ comp insurance carrier’s Petition for Review of Utilization Review Determination.

On appeal, however, the Workers’ Compensation Appeal Board (WCAB) reversed the decision of the WCJ.  The workers’ comp insurer was only responsible for the injuries described in the settlement documents, said the WCAB.  Since RSD/CRPS was not listed in those documents, the WCAB found the insurer not responsible for that treatment.

Upon Claimant’s appeal to the Commonwealth Court of Pennsylvania, the decision of the WCAB was reversed, making the insurer again responsible for the treatment.  The Court observed that the Utilization Review process is not the proper tool to dispute the relatedness of a condition.  Since that was the sum and substance of the argument raised by the insurer, such argument must fail.  As such, the Court ruled that the WCJ properly denied the insurer’s Petition for Review of Utilization Review Determination.

As to Claimant’s Petition to Review, to add RSD/CRPS to the injury, the Court agreed with the WCAB.  The work injury cannot be further expanded after the settlement.  This is to provide finality and certainty.  However, this does not mean the treatment at issue does not have to be paid by the insurer.  As the Court explained:

“In this case, Employer accepted responsibility for treatment for Claimant’s fractured feet. Thereafter, Claimant sought treatment for pain in those feet. There exists an obvious connection between the injury and the pain. For Employer to avoid responsibility for the medical expenses resulting from treatment of the pain in Claimant’s feet, Employer must prove that the treatment is for an injury that is distinct from the acknowledged injury.”

Since the insurer failed to meet that burden, the treatment for the pain remains payable by the insurer, regardless of the diagnosis that is attached to that pain.