G.O. Carlson, Inc. v. WCAB (Trauterman)

CourtCommonwealth Court of Pennsylvania
DecidedMarch 12, 2019
Docket1068 C.D. 2018
StatusUnpublished

This text of G.O. Carlson, Inc. v. WCAB (Trauterman) (G.O. Carlson, Inc. v. WCAB (Trauterman)) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
G.O. Carlson, Inc. v. WCAB (Trauterman), (Pa. Ct. App. 2019).

Opinion

IN THE COMMONWEALTH COURT OF PENNSYLVANIA

G.O. Carlson, Inc., : Petitioner : : v. : No. 1068 C.D. 2018 : Submitted: November 16, 2018 Workers’ Compensation Appeal : Board (Trauterman), : Respondent :

BEFORE: HONORABLE RENÉE COHN JUBELIRER, Judge HONORABLE PATRICIA A. McCULLOUGH, Judge HONORABLE CHRISTINE FIZZANO CANNON, Judge

OPINION NOT REPORTED

MEMORANDUM OPINION BY JUDGE COHN JUBELIRER FILED: March 12, 2019

G.O. Carlson, Inc. (Employer) petitions for review of the Order of the Workers’ Compensation Appeal Board (Board) affirming the decision of a Workers’ Compensation Judge (WCJ) that granted the Petition for Penalties (Penalty Petition) filed by Charles Trauterman (Claimant). The WCJ concluded Employer violated the Workers’ Compensation Act1 (Act) by denying payment for medical treatment, including a proposed lumbar fusion surgery, which the WCJ found to be causally related to Claimant’s work injury. On appeal, Employer argues the Board erred because: the proposed surgery was not causally related to Claimant’s accepted work injury; Employer had good reason for not preauthorizing the surgery; and the WCJ and Board did not consider that Employer ultimately did, in good faith, preauthorize

1 Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §§ 1-1041.4, 2501-2708. the surgery in December 2015, subject to its right to file a utilization review (UR). Discerning no error or abuse of discretion, we affirm. Claimant, a steel worker, sustained a work-related injury on January 12, 2009. Employer issued a Notice of Compensation Payable (NCP), describing the injury as a lumbar strain and accepting liability therefor. Claimant returned to light-duty work on January 22, 2009, and eventually returned to full duty. On July 20, 2015, Claimant filed the Penalty Petition asserting that Employer violated Section 306(f.1)(1) of the Act, 77 P.S. § 531(1), by refusing to preauthorize a lumbar fusion surgery recommended by Claimant’s treating physician without Employer having received a supersedeas or “properly challenging the reasonableness and necessity of the surgery.” (WCJ Decision, Finding of Fact (FOF) ¶ 2.) In its answer, Employer denied the Penalty Petition’s material allegations. The Penalty Petition was assigned to the WCJ, who held hearings at one of which Claimant testified. Claimant testified regarding the treatment for his back injury with James Macielak, M.D., beginning in August 2009. After years of treatment, Dr. Macielak suggested that Claimant undergo a L4, L5-S1 fusion, which was scheduled for June 3, 2015. Claimant explained the surgery did not happen because an adjuster from Employer’s insurer (Adjuster) advised him that Employer “wouldn’t cover anything until [Claimant] had a second opinion.” (Reproduced Record (R.R.) at 30a.) At Employer’s direction, Claimant went to Jon Levy, M.D., a board-certified orthopedic surgeon, for an Independent Medical Examination (IME) on June 10, 2015. Following Dr. Levy’s IME, Claimant still did not undergo the surgery, but he hoped he would be able to have it soon. Claimant acknowledged that Dr. Levy did not think the surgery was reasonable or necessary because Claimant was overweight

2 and smoked. Claimant has tried to stop smoking, but has been unsuccessful. He continued to treat with Dr. Macielak. Dr. Levy’s deposition and IME Report were submitted as evidence. In the IME Report, Dr. Levy explained that Claimant complained of low back pain with radicular symptoms in both lower extremities, which have been consistent since January 12, 2009. Dr. Levy observed there was no evidence that Claimant was magnifying his symptoms, and Claimant’s complaints of pain were consistent with the objective findings. He stated Claimant was not “fully recovered,” “ha[d] ongoing degenerative [disc] disease, ongoing lumbar radicular symptoms,” and the “preexistent degenerative disease . . . was potentially aggravated by the work event and has left him with residual lumbar radiculopathy.” (Id. at 76a.) Dr. Levy “believe[d] that [Claimant’s] current condition [wa]s directly and causally related to the work event of January 12, 2009” and did “not believe there [were] any non- work[-]related findings which contributed to [that] current situation.” (Id. at 76a- 77a.) According to Dr. Levy, the proposed surgery was not reasonable due to Claimant being a heavy smoker and complaining more of axial (back) pain than radicular pain. Dr. Levy believed that Claimant’s heavy smoking made the surgery more likely to fail, making it an option of last resort, and that the surgery likely would not be successful in resolving Claimant’s back pain. Similar to the IME Report, Dr. Levy testified Claimant complained of “low back pain, bilateral lower extremity discomfort, numbness in his left foot on an intermittent basis, right leg pain radiating to his knee.” (Id. at 47a.) Dr. Levy’s review of Claimant’s x-rays taken shortly after the work injury revealed that Claimant had mild degenerative changes at L4-L5 that preexisted the work injury. Following his examination of Claimant and review of Claimant’s medical records

3 and diagnostic studies, Dr. Levy diagnosed Claimant with lumbar degenerative disc disease, which preexisted the work injury but was potentially aggravated by the work injury, lumbar strain, and lumbar radiculopathy. Dr. Levy indicated he was not aware that the lumbar radiculopathy existed prior to the work injury, and acknowledged that some lumbar strains never fully recover. (Id. at 53a-54a.) Dr. Levy agreed that Claimant was not fully recovered from the work injury, and Claimant’s current condition was “directly and causally related to the work event of January 12, 2009.” (Id. at 57a.) On the issue of the proposed surgery, Dr. Levy recounted Claimant’s history of heavy smoking, which was a contraindication for lumbar fusion surgery because smokers do worse with surgical intervention. He indicated that smokers have a higher incidence of back pain and that smoking accelerates degenerative conditions, such as degenerative disc disease. Considering that a lumbar strain is a soft tissue injury, Dr. Levy opined that a lumbar fusion is not a treatment for soft tissue injuries, so he did not believe this to be the reason for the surgery. However, Dr. Levy also indicated that while the degenerative condition played a role in the proposed surgery, it was “impossible to ascertain what percentage of [Claimant’s] symptoms related to the normal aging process in a smoker, versus someone who had an injury six years prior” and “if Claimant [had] never recovered . . . in my opinion, . . . there is a causal relationship between his work event and his problem.” (Id. at 63a-64a.) He further opined the surgery was not reasonable or necessary because surgeries are usually more successful at relieving leg pain, rather than back pain, and are less successful for smokers. Because Claimant complained more of back pain than leg pain and was a heavy smoker, Dr. Levy did not consider Claimant a good candidate for the surgery. Dr. Levy also acknowledged that Claimant had undergone a long period of

4 conservative care, smokers do sometimes have this surgery, and surgery was a potential option. (Id. at 58a, 61a-62a.) The parties stipulated that Adjuster called Claimant and left a message stating, “I just wanted to let you know based on your IME, we will not be approving surgery” and that “we will not [be] approving anything based on that IME report.” (Id. at 27a.) On December 23, 2015, Adjuster sent Dr. Macielak a fax “confirm[ing its] willingness to preauthorize the . . . surgery [he] recommended with the reservation of our right to review the bill before making payment to make certain it is reasonable and necessary.” (Id. at 79a.) Employer’s counsel acknowledged at the hearing that Employer had not filed a prospective UR petition challenging the reasonableness and necessity of the proposed surgery.

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G.O. Carlson, Inc. v. WCAB (Trauterman), Counsel Stack Legal Research, https://law.counselstack.com/opinion/go-carlson-inc-v-wcab-trauterman-pacommwct-2019.