Medical Treatment in PA Workers’ Comp Not Reasonable or Necessary Because No Significant Improvement

Utilization Review is the proper course of action when either party in a PA workers’ compensation case questions whether medical treatment is reasonable and necessary. We have discussed this process in a previous blog entry.

Since the Pennsylvania Workers’ Compensation Act is remedial legislation, intended by its creators to provide the injured worker with the benefit of the doubt, what is considered “reasonable and necessary” does not have to cure a condition. As PA Courts have previously stated, “Treatment may still be reasonable and necessary ‘even when it is designed to manage the claimant’s symptoms rather than to cure or permanently improve the underlying condition.'”

A recent case, Gary v. Workers’ Compensation Appeal Board (Philadelphia School District), decided by the Commonwealth Court of Pennsylvania seems to certainly blur this line. In 2001, Ms. Gary injured her neck and back while working. Then, in 2003, a Utilization Review Determination found the treatment of a chiropractor to be reasonable and necessary.

The workers’ comp insurance carrier, undaunted, again sought Utilization Review in 2008, on the same chiropractor, concerning the same treatment. The Workers’ Compensation Judge (WCJ) found the Utilization Reviewer credible, when the Reviewer said the treatment at issue was not reasonable or necessary because it failed to show significant improvement. The testimony of the injured worker, that the treatment gave her relief, was not believed by the WCJ. In her decision, the WCJ did not even mention the 2003 Utilization Review Determination. This was affirmed by the Workers’ Compensation Appeal Board (WCAB).

Upon further appeal, the Commonwealth Court of Pennsylvania also affirmed. The Court noted that the failure of the WCJ to even mention the 2003 Utilization Review (regarding the same provider, giving the same treatment) was harmless, given the period of time in between the two URs, and the fact that the WCJ credited evidence showing a change in condition in that span of time. Further, the Court found that, while treatment can be reasonable and necessary while still simply relieving pain, the WCJ credited the testimony of the Utilization Reviewer, who found the treatment did not yield “significant improvement.” As such, the Court concluded, the workers’ comp insurance carrier met its burden of proving the chiropractic treatment was not reasonable or necessary.

As attorneys who limit their practice to representing injured people in PA workers’ compensation cases, we were greatly disappointed in this decision. Though the Court gave lip service to the proper standard, that treatment can be reasonable and necessary simply because it relieves pain, ultimately, the Court ignored the concept. The use of the term “significant improvement” as part of the reasoning behind the decision demonstrates the lack of true understanding. Workers who have severe injuries, such as disc herniations in the cervical or lumbar spine, separated shoulders, total knee replacements, thoracic outlet syndrome and complex regional pain syndrome, just to name a few, find simple pain relief, even if only temporary, to be worth an incalculable price. Sadly, our court system believes otherwise.