J. Barnhart v. WCAB (Tremont Borough)
J. Barnhart v. WCAB (Tremont Borough) - 66 C.D. 2017
Pa. Commw. Ct.Aug 16, 2017Background
- Claimant Jack Barnhart sustained a 1996 work-related back injury and has chronic pain treated by neurologist Dr. John Chawluk with OxyContin, immediate-release oxycodone, Lidoderm, and Provigil (modafinil) for daytime somnolence.
- Employer requested utilization review (UR) of the prescriptions in December 2014; UR reviewer Dr. Jon Glass concluded Provigil was not reasonable/necessary because literature supports its use for narcolepsy, obstructive sleep apnea, and shift‑work disorder, not opioid‑related somnolence.
- Claimant testified Provigil improves wakefulness; Dr. Chawluk supported off‑label use of Provigil for opioid‑related somnolence but could not cite specific literature.
- The Workers’ Compensation Judge (WCJ) found Dr. Glass credible and Dr. Chawluk not credible, concluding Provigil was not reasonable and necessary.
- The Workers’ Compensation Appeal Board affirmed; Claimant appealed to this Court arguing lack of substantial evidence and alleged capricious disregard of his proof.
Issues
| Issue | Barnhart's Argument | Tremont Borough's Argument | Held |
|---|---|---|---|
| Whether Provigil is reasonable and necessary to treat somnolence from prescribed opioids | Provigil is needed to counteract opioid‑induced somnolence; Claimant and his treating physician observed benefit | UR reviewer opined no medical literature supports Provigil for opioid‑related somnolence; listed approved indications only | WCJ and Board: Provigil not reasonable/necessary; substantial evidence supports denial |
| Whether WCJ capriciously disregarded Claimant's evidence | WCJ ignored testimony showing symptom relief with Provigil | WCJ weighed competing medical opinions and credited UR reviewer | Court: No capricious disregard; credibility determinations stand |
| Burden of proof in UR dispute | N/A (Claimant argued his evidence was sufficient) | Employer bears burden to prove treatment not reasonable/necessary | Employer presented a UR report; Court found substantial evidence supporting WCJ's decision |
| Admissibility/weight of off‑label use evidence | Off‑label use and clinical experience suffice to show effectiveness | Off‑label use without supporting literature insufficient | Court: Off‑label use alone, without supporting evidence, did not overcome UR reviewer’s contrary opinion |
Key Cases Cited
- AT&T v. Workers' Comp. Appeal Bd. (DiNapoli), 816 A.2d 355 (2003) (employer bears burden to prove treatment not reasonable/necessary in UR dispute)
- Minicozzi v. Workers’ Comp. Appeal Bd. (Indus. Metal Plating, Inc.), 873 A.2d 25 (2005) (WCJ has exclusive province over credibility and evidentiary weight)
- Sell v. Workers’ Comp. Appeal Bd. (LNP Eng’g), 771 A.2d 1246 (2001) (appellate role is to determine if WCJ’s findings have record support)
- Williams v. Workers’ Comp. Appeal Bd. (USX Corp.-Fairless Works), 862 A.2d 137 (2004) (definition of capricious disregard requires deliberate baseless ignoring of trustworthy evidence)
- Lindemuth v. Workers’ Comp. Appeal Bd. (Strishock Coal Co.), 134 A.3d 111 (2016) (substantial evidence standard explained)
- Wise v. Unemployment Comp. Bd. of Review, 111 A.3d 1256 (2015) (capricious disregard standard and rare overturn on that basis)
- Bedford Somerset MHMR v. Workers’ Comp. Appeal Bd. (Turner), 51 A.3d 267 (2012) (upholding denial where medication lacked appropriate indication for claimant’s condition)
- Elberson v. Workers’ Comp. Appeal Bd. (Elwyn, Inc.), 936 A.2d 1195 (2007) (scope of review limited to substantial evidence, legal error, or constitutional issue)