Medical Benefits

November 22, 2024

DHS Lien Not Automatically Reimbursable Under PA Workers’ Comp

While perhaps not of interest to every injured worker, the subject of PA Department of Human Services’ (DHS) liens is one that appears from time to time in Pennsylvania workers’ compensation cases. And, while the injured workers may not have a huge interest, the PA workers’ compensation insurance companies surely feel otherwise. The topic can easily (as in the case we will discuss) feature bills of over $100,000.

In the case we will be addressing (Dura-Bond Coating, Inc. v. R. Marshall & PI&I Motor Express (WCAB)), the injured worker suffered a catastrophic work injury, leading to the amputation of both of his legs. Given that there was a dispute as to what entity was actually his “employer,” there was considerable litigation following the filing of a Claim Petition.

While the Claim Petition was being litigated, medical bills were not being paid by any workers’ compensation insurance carrier. This resulted in bills being paid through DHS. In a situation like this, where DHS pays for treatment that should be borne by another party, DHS has a lien to recover payments it has made.

December 20, 2023

PA Workers’ Compensation Insurance Carrier Must Pay Bill for Medical Treatment or Seek Utilization Review

by Glenn Neiman

Under the Pennsylvania Workers’ Compensation Act, the insurance carrier has 30 days to either pay a medical bill for treatment related to a work injury, or file for Utilization Review (to challenge whether such treatment is reasonable and necessary). The question, at times, is whether the treatment is “related” to the work injury or not. Some workers’ comp insurance carriers simply deny payment, alleging the bills are for treatment unrelated to the work injury. A recent decision by the Commonwealth Court of Pennsylvania casts doubt on this type of response.

First, it is important to note that this decision is “unreported,” and is only persuasive (not binding). In Pennsylvania Liquor Control Board v. 3B Pain Management (Bureau of Workers’ Compensation Fee Review Hearing Office), the injured worker fell in the parking lot outside the store. A Claim Petition was filed and litigated. Ultimately, the Workers’ Compensation Judge granted the Claim Petition, finding the work injury to be a “meniscal tear of the right knee and chondromalacia of the femoral and tibial condyle of the right knee.”

The injured worker had chiropractic treatment, which the Court described as, “ . . . spinal manipulation relating to low back pain, manipulation of Claimant’s knees and his right hip for pain, low level laser treatment on his right knee, and therapeutic massage for unidentified muscle spasms.”

November 15, 2023

CBD Oil is Payable Under PA Workers’ Compensation

by Glenn Neiman

We often have issues regarding whether a particular medical expense is payable by the workers’ compensation insurance carrier. The issue could be whether it is a “medical” treatment at all, whether it is related to the work injury, or whether it is “reasonable or necessary.” A recent case from the Commonwealth Court of Pennsylvania examined a few of these issues.

In M.R. Schmidt v. Schmidt, Kirifides and Rassias, PC (Workers Compensation Appeal Board), the injured worker (Claimant) suffered an “aggravation of a preexisting degenerative disc disease at the levels of L4-5 and L5- S1 with radiculopathy” while he was loading files into a bag. The injured worker litigated, and won, a Claim Petition to have this injury accepted as compensable. Despite his injury, Claimant continued to work with the assistance of pain management. In an effort to avoid increasing the amount of Oxycodone and/or OxyContin he was taking, the pain management physician prescribed cannabinoid (CBD) oil. Since the dosages of the opioids has not been increased again, and Claimant has been able to avoid surgery, the use of CBD oil appears to have been successful.

The Pennsylvania Workers’ Compensation Act (Act) requires that the insurance carrier pay for all reasonable and necessary medical treatment related to the work injury. As such, Claimant provided the insurance carrier with the prescription for the CBD oil, as well as his out-of-pocket receipts. The insurance carrier refused to reimburse these expenses, alleging that CBD oil is not a “pharmaceutical drug.” As a result, Claimant filed a Petition for Penalties.

October 3, 2023

Types of Diagnostic Testing Used for PA Workers’ Compensation Spinal Injuries

by Glenn Neiman

When an injured worker in Pennsylvania hurts his or her spine, there are many diagnostic tests that a doctor may prescribe. Sometimes, the doctors do not fully explain what a test is, or what it may show. We believe that an injured worker should be fully informed, whether as to the legal aspects of his or her case, or the medical aspects. While we are certainly not doctors, and would never suggest or recommend treatment, if the doctor will not educate his or her patient, that responsibility can fall to us. We believe our clients are best served by being fully informed about what is happening in their case, both medically and legally.

From our experience, the first thing a doctor does when seeing a patient for a work injury to the neck or back is get x-rays. An x-ray will show bone, such as a fracture (including, potentially, a stress fracture), but will not visualize soft tissue, like discs, muscles, tendons or ligaments. This would be to rule out the presence of a fracture (though, if a fracture is still suspected, a bone scan can be done to better analyze the presence or absence of a fracture).

If the injured worker has pain, numbness or tingling into one or both arms, or one or both legs, a doctor may suspect the presence of “radiculopathy” or “radiculitis”, meaning that a nerve is possibly being pinched or touched by another structure, either a bulging or herniated disc, or due to “stenosis,” a narrowing of the spine which can be degenerative (though stenosis can be “aggravated” by an injury at work). To assess the discs, and degree of stenosis, doctors often prescribe an MRI, with or without contrast. The results of the MRI may help the doctor determine whether surgery can help reduce the pressure on the nerve, to potentially relieve the radiating symptoms to the arm or leg.

August 3, 2020

In a PA Work Injury, Concussion Can Be Confused With Whiplash

by Glenn Neiman

We have previously discussed on this blog the difficulties in differentiating shoulder injuries to injured workers, noting that according to medical literature, several conditions can account for similar symptoms in a similar area. Some recent articles have now shed light on some difficulties in diagnosing a concussion versus a whiplash injury, given the similar presentation between the two conditions.

According to an article in the Journal of Orthopedic & Sports Physical Therapy, since the presenting symptoms of concussion and whiplash can be similar (neck pain, headache, dizziness, and concentration deficits), and the causes of both conditions (biomechanically) is similar, there is a very real risk of misdiagnosis. This is seems especially prevalent in the workers’ compensation system where panel physicians hesitate to refer injured workers to specialists, or for diagnostic testing, to avoid angering either the employer or the workers’ compensation insurance carrier. The very nature of the panel physician/employer relationship unfortunately creates an incentive for the panel physician to undertreat the injured worker and return him or her to full duty before the injured worker is ready to do so.

While many times either a concussion or whiplash will resolve within a three month period, in those cases where it does not, misdiagnosis can be very dangerous. Paul Lagerman (“a Physiotherapist with 20 years of experience in pain management, musculoskeletal injury and rehabilitation”), posted a deep analysis of this problem, along with the dangers and effects of not understanding what condition is actually in need of medical treatment. This can cause the problem to linger far longer than necessary.

December 12, 2019

Pharmacy Must be Given Due Process When Dispensing Medications for Work Injury in PA

by Glenn Neiman

We have discussed the Utilization Review (UR) process many times in this blog. Indeed, UR is such a big issue in the world of Pennsylvania workers’ compensation that we have a section on our website devoted to just this topic. Basically, UR is the tool used by either an injured worker, or the workers’ compensation insurance carrier (usually the latter) to determine whether medical treatment is “reasonable and necessary.”

A somewhat related process is that for Fee Review. Since this is something that is done by healthcare providers (rather than the injured worker), we have rarely addressed Fee Review in this blog. The healthcare providers often have their own legal counsel handle these matters (rather than obtaining relief through the efforts of the injured worker’s attorney, as in other areas of workers’ comp). Fee Review is the means a healthcare provider uses to obtain payment for reasonable and necessary medical treatment, related to the work injury. Recently, the Commonwealth Court of Pennsylvania issued a decision which dealt with both Utilization Review and Fee Review.

In Keystone Rx LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office (Compservices Inc./AmeriHealth Casualty Services), the injured worker hurt his left knee. As part of the treatment for the knee, the physician ordered medications, which were dispensed by Keystone Rx LLC. The workers’ compensation insurance carrier filed for Utilization Review of the treatment rendered by the physician, including these prescriptions. A Utilization Review Determination found all treatment of the physician, including the medications, to be unreasonable and unnecessary. This meant the insurance company was not responsible for payment of the treatment found unreasonable and unnecessary (including the prescriptions).

November 21, 2019

Contusions or Bruises Can Be Serious Injuries in PA Workers’ Compensation

by Glenn Neiman

How many times must an injured worker in PA hear something like, “Why are you still out of work – it was just a bruise?” What is not widely understood is that a bruise, or a contusion, can, indeed, be a serious injury with very severe consequences. Recently, we saw an example of this in the sports world.

Tyler Lockett, a wide receiver for the Seattle Seahawks in the NFL, suffered a bruised lower leg in a game on November 11, 2019. According to an article in the Washington Post, Mr. Lockett was hospitalized overnight as a result of the injury. In addition to causing pain and immobility, a bruise or contusion can also cause swelling. This swelling, when in a small area, such as a lower leg, can instigate “compartment syndrome.” According to the article, “Compartment syndrome is a rare but potentially dangerous condition in which pressure builds to extreme levels in a limb after it undergoes some sort of trauma, either from a big hit or simple exercise.”

On the website for the American Academy of Orthopaedic Surgeons (AAOS), it is reiterated that compartment syndrome can result from badly bruising a muscle, which we do often see in PA workers’ compensation cases. When this compartment syndrome is the result of acute trauma, it is a medical emergency. Immediate treatment is necessary to avoid permanent damage to muscle, nerve and tissue. There is no non-surgical treatment for compartment syndrome. Specifically, the treatment involved would be:

November 1, 2019

Fusion a Pain in the Neck (or Back) for Injured Workers – Adjacent Segment Disorder and Adjacent Segment Pathology

by Glenn Neiman

The vast majority of work injuries in Pennsylvania heal with conservative treatment, allowing the injured worker to return both to work, as well as to activities of normal life. However, there are certainly the more serious injuries, where more invasive medical treatment is required.

Often the more invasive treatment options entail surgery. When we are talking about work injuries to the neck and back, the procedures we usually see are laminectomy, microdiscectomy and traditional lumbar fusion. For a description of each of these, and more information regarding these procedures, check out this post from Penn Medicine. For our purposes today, we are looking at the traditional lumbar fusion. As explained in the Penn Medicine article:

“Traditional spinal fusions are used to treat instability of the spine, scoliosis, severe degeneration of the discs, or a combination of these issues. A fusion involves using bone from the patient’s body to fuse one vertebrae to another. Often, metal screws (pedicle screws) are placed into the vertebrae to assist with the fusion process.”

October 23, 2019

Brilliant & Neiman LLC attending Rothman Orthopedic Institute’s Workers’ Compensation Conference

by Glenn Neiman

While we are very conscious of being available to our clients as much as possible, the practice of PA workers’ compensation law, and the litigation process, means we are not always in our offices. Sometimes, in addition to being at workers’ compensation hearings and depositions, our attorneys attend events or presentations that may help us better perform our job protecting the injured worker in PA.

And, so it follows, our attorneys were invited by Rothman Institute to attend their Workers’ Compensation Conference, being held all day on Friday, October 24, 2019. We sincerely apologize if this means we are not available to help our clients on that day directly, though our office staff certainly remains available (and can reach the attorneys for any emergencies). As our clients know, it is the practice of Brilliant & Neiman LLC for the clients to speak directly to the attorney, rather than being forced to always speak to support staff. We apologize for this deviation from our regular course of business.

The Workers’ Compensation Conference will no doubt provide our attorneys with additional tools to help us best protect the rights of injured workers in PA. Topics being presented will include 3-D printing in orthopedic surgery, issues with complex rotator cuff surgery, as well as general updates regarding treatment options for injuries to the neck, back and knees. The Workers’ Compensation Conference will be moderated by Dr. Nicholas Taweel, and will include presentations from Dr. Pedro Beredjiklian, Dr. Mark Lazarus, Dr. Michael Molter, Dr. Howard Yeon and Dr. Paul Steinfield.

February 11, 2019

Too Many Total Knee Replacements Being Performed?

by Glenn Neiman

As far back as 2008, our blog reported on a marked increase in the number of total knee replacements that were being performed. This trend seems to have been continuing, and, perhaps, not for the best. According to a recent article in The Intelligencer, a rather high number of patients who elected to have a total knee replacement performed, were dissatisfied with the results. According to the article:

“Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published last year in the BMJ found that knee replacement had “minimal effects on quality of life,” especially for patients with less severe arthritis.”

In Pennsylvania workers’ compensation, a total knee replacement is a procedure with see with some regularity. Whether the injured worker had a preexisting arthritic condition, which was aggravated by a work injury, or whether the work injury itself led directly to the procedure, a total knee replacement is not uncommon in a workers’ comp case.