Bedford Somerset MHMR v. Workers' Compensation Appeal Board (Turner)
51 A.3d 267
Pa. Commw. Ct.2012Background
- Claimant Linda Turner sustained a December 1987 work injury for Bedford Somerset MHMR with multiple pain-related diagnoses (arachnoiditis, failed fusion, neuropathy, chronic pain, disci-tis, osteomyelitis, spinal stenosis).
- May 2009, Employer filed a utilization review (UR) petition challenging Claimant’s treatment by Dr. Maharajh, including a fentanyl patch and fentanyl lozenges for breakthrough pain.
- UR reviewer found the fentanyl patch and visits reasonable, but fentanyl lozenges not reasonable/necessary because the lozenges are FDA-approved only for cancer-related pain due to high addictiveness.
- Claimant testified she has tried at least 12 other medications with limited relief or intolerable side effects, and the fentanyl lozenges provide rapid, essential breakthrough pain relief.
- WCJ adopted Employer’s UR-based conclusion that fentanyl lozenges were not reasonable/necessary due to addiction risk, with potential for alternative regimens; Board reversed, creating the current appeal.
- This Court reverses the Board and reinstates the WCJ’s decision, affirming that the fentanyl lozenges were not reasonable/necessary within the UR framework.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the UR determination was properly applied. | Turner; Board erred by overturning credibility and UR weight. | Employer; WCJ properly relied on UR andmedical testimony. | Yes; UR-based reasonableness/necessity supported denial. |
| Whether the Board properly evaluated medical evidence and credibility. | Credibility favored Claimant’s testimony on pain control. | WCJ credibility should be respected; Board erred in substituting views. | Yes; WCJ credibility findings binding on appeal. |
| Whether evidence supports not reasonable/necessary nature of fentanyl lozenges due to addiction risk. | Alternative treatments exist but were not viable for her condition. | Addictive risk and lack of indication support denial. | Yes; highly addictive nature and medical testimony justify denial. |
| Whether the FDA labeling limiting fentanyl lozenges to cancer-related pain affects reasonableness/necessity. | FDA labeling should not inherently bar reasonable/necessary treatment. | Appropriate to consider FDA labeling in UR determinations. | Yes; labeling factored into reasonableness/necessity analysis. |
Key Cases Cited
- Sweigart v. Workers’ Comp. Appeal Bd. (Burnham Corp.), 920 A.2d 962 (Pa.Cmwlth.2007) (UR may consider risk/long-term effects of narcotics in determining reasonableness)
- CVA, Inc. v. Workers’ Comp. Appeal Bd. (Riley), 29 A.3d 1224 (Pa.Cmwlth.2011) (UR burden on employer to show treatment not reasonable/necessary)
- Topps Chewing Gum v. Workers’ Comp. Appeal Bd. (Wickizer), 710 A.2d 1256 (Pa.Cmwlth.1998) (employer bears burden in UR; claimant bears none)
- Howrie v. Workers’ Comp. Appeal Bd. (CMC Equip. Rental), 879 A.2d 820 (Pa.Cmwlth.2005) (deference to WCJ credibility determinations)
- Sell v. Workers’ Comp. Appeal Bd. (LNP Eng’g), 565 Pa. 114, 771 A.2d 1246 (2001) (apellate review limited to support in record; not reweighing equivalence)
- Minicozzi v. Workers’ Comp. Appeal Bd. (Indus. Metal Plating Inc.), 873 A.2d 25 (Pa.Cmwlth.2005) (WCJ credibility determinations binding on appeal)