Seamon v. Workers' Compensation Appeal Board

761 A.2d 1258, 2000 Pa. Commw. LEXIS 601, 2000 WL 1678054
CourtCommonwealth Court of Pennsylvania
DecidedNovember 9, 2000
Docket716 C.D. 1998
StatusPublished
Cited by25 cases

This text of 761 A.2d 1258 (Seamon v. Workers' Compensation Appeal Board) 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
Seamon v. Workers' Compensation Appeal Board, 761 A.2d 1258, 2000 Pa. Commw. LEXIS 601, 2000 WL 1678054 (Pa. Ct. App. 2000).

Opinions

LEADBETTER, Judge.1

This case raises a question of first impression regarding the utilization review (UR) provisions of the Workers’ Compensation Act (Act).2 On April 30, 1999, this court granted reargument before the court en banc to consider whether the failure of a utilization review organization (URO) to obtain medical records from all other treating providers, as required by applicable regulations, renders the UR report inadmissible in subsequent proceedings before a Workers’ Compensation Judge (WCJ) to determine the reasonableness and necessity of medical treatment under review.3

[1260]*1260On March 28, 1984, Peter Robert Seam-on (claimant) sustained injuries to his neck and back during the course and scope of his employment with Sarno & Son For-máis. As required by the Act, claimant’s medical expenses were paid and he received partial disability benefits. On July 13, 1989, claimant’s partial disability benefits of $14.60 per week were commuted for the remainder of his eligibility.

As a result of his injuries, claimant received chiropractic treatment from Dr. Joseph Gnall until September 1994 when he relocated from Pennsylvania to Tucson, Arizona. Thereafter, beginning September 28, 1994, claimant sought chiropractic treatment in Tucson with Dr. David Welch. On January 6, 1995, Sarno challenged the reasonableness or necessity of Dr. Welch’s treatment of claimant by fifing a request for utilization review pursuant to Section 306(f.l)(6) of the Act, 77 P.S. § 531(6).4 The Bureau of Workers’ Compensation (Bureau) appointed Medical Planning and Review as the URO, which in turn selected chiropractor Jeff A. Behrend as the reviewing doctor. Dr. Behrend reviewed Dr. Welch’s medical file on claimant, which the URO had obtained. In his report to the URO, Dr. Behrend concluded that Dr. Welch’s chiropractic treatment of claimant was not reasonable or necessary. Specifically, Dr. Behrend opined as follows:

The records provided for review, establish an uncomplicated strain/sprain to a 30-year-old male. This would have an expected natural course extending over [8] to [16] weeks. The records indicate that the patient received both medical and chiropractic care during the period between the date of injury and the onset of chiropractic care with Dr. Welch, September 28, 1994. This care is not well defined, but there is evidence that the patient may have received an adequate course of chiropractic care.
Chiropractic care began with Dr. Welch over [10] years after the injury occurred. The patient received protocol of manipulation, traction and massage. This is a passive modality protocol and is usually applied for a period of [8] to [12] weeks.... This would not be an appropriate protocol this long after the injury occurred.
The records provided from Dr. Welch do not provide a clear rationale for continuing chiropractic care at the time treatment was assessed with him, [10] years after the injury occurred. There is no discussion of the patient’s previous treatment plan or clinical outcome. Considering the patient’s history, this would have been appropriate. The records do not provide an adequate rationale to continue the treatment protocol provided by Dr. Welch....

Medical report of Dr. Behrend, dated March 17,1995, at 2-3.

On April 8, 1995, claimant filed a timely utilization review reconsideration request with the Bureau.5 Chiropractor Jess P. [1261]*1261Armine performed the second review of Dr. Welch’s treatment. Dr. Armine also reached the conclusion that the treatment delivered by Dr. Welch was not reasonable or necessary. Specifically, Dr. Armine stated in his report that:

It is my professional chiropractic opinion that the care rendered this patient from September 28, 1994 onward is not reasonable and necessary for the following reasons.
There is no documentation showing that this patient required/obtained care on a reasonably continuous basis from the accident of 1984 to the present time. According to the initial intake forms the patient indicates that he had care for approximately 3 years post accident but follow-up care after that is vague at best. Further, there is no objective documentation, diagnostic findings, etc. showing that would lead one to conclude that this patient would require ongoing chiropractic care. Therefore, it is my opinion that the care rendered this patient from 9/28/94 onward is not reasonable and necessary.

Medical report of Dr. Armine, dated May 19, 1995, at 2. Dissatisfied with this outcome, claimant filed a timely utilization review petition on July 5, 1995. A de novo hearing was conducted before a WCJ, in which Sarno had the burden of proving that the treatment rendered by Dr. Welch was not reasonable and necessary.6 In support of his petition, claimant offered into evidence the office notes of Drs. Welch and Gnall. Sarno, in turn, offered the UR reports of Drs. Behrend and Ar-mine. Based on his review of the record, the WCJ issued a decision and order finding that Sarno had met its burden of proving that Dr. Welch’s treatment was not reasonable or necessary. The Workers’ Compensation Appeal Board (Board) affirmed and the present appeal followed.

Claimant asserts that the URO failed to obtain the medical records from his earlier treating doctors, in violation of applicable regulations. He argues that such a failure renders the UR determinations inadmissible, or at least incompetent to support a finding that treatment was not reasonable or necessary, and precludes a “fair and impartial review” by the WCJ of the issue. Even assuming, arguendo, the accuracy of claimant’s factual representations, which employer challenges, he is not entitled to relief.

Claimant is correct that in addition to obtaining the records of the provider under review, the Bureau’s regulations require the URO at least to make reasonable efforts to obtain the available records of all other providers rendering treatment for the work-related injury. Specifically, the regulations provide, in pertinent part:

§ 127.407. Extent of review of medical records.
(a) In order to determine the reasonableness or necessity of the treatment under review, URO’s shall obtain for review all available records of all treatment rendered by all providers to the employe for the work-related injury. However, the UR determination shall be limited to the treatment that is subject to review by the request.
§ 127.459. Obtaining medical records — provider under review.
(a) A URO shall request records from the provider under review in writ-ing_ In addition, the URO may request the records from the provider under review by telephone.
(b) The medical records of the provider under review may not be requested from, or supplied by, any source other than the provider under review.
§ 127.460. Obtaining medical records-other treating providers.
[1262]*1262(a) A URO shall request records from other treating providers in writing. In addition, the URO may request records from other treating providers by telephone.

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Cite This Page — Counsel Stack

Bluebook (online)
761 A.2d 1258, 2000 Pa. Commw. LEXIS 601, 2000 WL 1678054, Counsel Stack Legal Research, https://law.counselstack.com/opinion/seamon-v-workers-compensation-appeal-board-pacommwct-2000.