83 A.3d 1139
Pa. Commw. Ct.2014Background
- Claimant Lancess Womack sustained work-related lumbar and knee injuries; Provider Dr. Terri Gartenberg (Philadelphia Pain Management) provided chiropractic care. Employer requested utilization review (UR) on Sept. 21, 2010 for treatment beginning Aug. 19, 2010 and ongoing.
- The assigned URO (Rehabilitation Planning, Inc.) reviewed Provider’s records and issued a UR determination on Nov. 15, 2010 concluding the treatment was unreasonable and unnecessary. Provider petitioned for review; the WCJ and the Workers’ Compensation Appeal Board (Board) upheld the UR denial.
- The URO received Provider’s records on Oct. 5, 2010; under statute/regulation the URO had 30 days from receipt (until Nov. 4, 2010) to issue its written determination, so the URO’s Nov. 15 report was untimely.
- Claimant argued the late URO determination was void and that treatment should be deemed covered; alternatively she asserted the WCJ (i) shifted the burden of proof to Provider, (ii) applied improper standards in assessing reasonableness/necessity, and (iii) failed to issue a reasoned decision.
- The WCJ credited the URO reviewer’s conclusions that Provider’s records lacked specific treatment goals, objective outcome measures, and adequate documentation of progress; the WCJ found treatments not reasonable or necessary from Aug. 19, 2010 onward.
- The Commonwealth Court affirmed the Board: the URO’s late report did not void the UR result because the URO (a nonparty) missed the deadline; the WCJ did not improperly shift the burden, applied correct standards, and issued a reasoned decision supported by substantial evidence.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Timeliness of URO determination — consequence of late report | URO missed statutory/regulatory deadline; late UR is void and treatment should be covered | URO’s noncompliance does not prejudice Employer; statute/regulation do not mandate voiding UR determinations when a nonparty URO is late | Held: URO’s untimely report does not render UR decision void ab initio; no basis to impose that consequence on Employer/parties |
| Burden of proof shift | WCJ improperly shifted burden to Provider to justify treatment in records | Employer carried burden to show treatments unreasonable; reviewer noted missing info and WCJ drew permissible negative inferences; claimant had opportunity to rebut | Held: No improper burden shift; WCJ permissibly relied on reviewer and adverse inferences from incomplete records |
| Standard for reasonableness/necessity — reliance on lack of objective goals/outcomes | WCJ erred by requiring objective goals/outcomes; palliative relief alone may suffice | Regulations and case law permit considering objective treatment plans, goals, and outcomes; missing documentation supports negative determination | Held: WCJ applied proper standards; absence of treatment goals/outcomes and lack of progress supports finding treatment not reasonable or necessary |
| Reasoned decision requirement | WCJ capriciously discredited previously-credited testimony and failed to explain conflicts | WCJ explained weight given to testimony and basis for findings; credibility and weight are for factfinder | Held: WCJ issued a reasoned decision supported by substantial evidence; affirmation by Board affirmed |
Key Cases Cited
- Fishkin v. Hi-Acres, Inc., 341 A.2d 95 (Pa. 1975) (distinguishes mandatory vs. directory statutory requirements and effect of noncompliance)
- Lackawanna County Tax Claim Bureau v. In re Sale of Real Estate, 22 A.3d 308 (Pa. Cmwlth.) (time provisions for public entities generally construed directory unless essential to statutory purpose)
- Gardner v. Workers' Compensation Appeal Board (Genesis Health Ventures), 888 A.2d 758 (Pa. 2005) (certain statutory timelines in workers’ compensation IRE process are mandatory because they are essential to the statutory scheme)
- West Penn Power Co. v. Pennsylvania Public Utility Commission, 521 A.2d 75 (Pa. Cmwlth. 1987) (time limits imposed on adjudicatory body are typically directory; failure by adjudicator does not void proceedings)
- Seamon v. Workers' Comp. Appeal Bd., 761 A.2d 1258 (Pa. Cmwlth. 2000) (UR reviewers assess reasonableness/necessity in context of entire course of care)
- Solomon v. Workers' Compensation Appeal Bd. (City of Philadelphia), 821 A.2d 215 (Pa. Cmwlth. 2003) (records lacking rationale for continued chiropractic care support UR denial)
- Jackson v. Workers' Comp. Appeal Bd. (Boeing), 825 A.2d 766 (Pa. Cmwlth. 2003) (palliative care can be reasonable, but lack of objective improvement and plan may render continued passive modalities unreasonable)