Case Law Summary

January 22, 2014

Womack v. WCAB (The School District of Phila), __ A.3d __ (Pa. Cmwlth., No. 1137 C.D. 2013, filed January 14, 2013)

 

In Womack, the WCJ denied the claimant’s UR Petition, finding the treatment under review neither reasonable nor necessary. The WCAB affirmed. Through her appeal, the claimant first argued that the UR Determination should have been considered void because it was not issued within the time period prescribed by Section 306(f.1)(6)(ii) of the Act. The Commonwealth Court disagreed, noting that the employer itself had not failed to meet a statutory deadline or regulatory deadline. Rather, it was the URO that had clearly failed to comply with the Department’s regulations. The Court commented that while the URO’s conduct might place it at risk of losing its authorization to conduct utilization reviews in the future, there was no basis in the Act, regulations or case law to impose the additional consequence of vacating the URO’s decision as void simply because it failed to issue the determination within the proscribed time line.

 

The claimant raised a number of additional arguments, all of which were rejected by the Commonwealth Court. First, the Court found that the WCJ had not improperly shifted the burden from the employer to the provider during the utilization review proceedings, where the claimant was well aware of the reviewer’s position in finding the treatment under review neither reasonable nor necessary, yet failed to rebut the opinion with viable evidence during the proceedings. Second, the Court disagreed that the utilization review should have resolved in the provider’s favor where the reviewer indicates that he cannot make a determination regarding the reasonableness and necessity of treatment because the records of the provider did not include plans and objectives. The Court observed that a URO is authorized to reach a negative conclusion where a provider submits incomplete or non-comprehensive records. The Court cautioned that providers bear the risk, in the utilization review process, that any missing information will be deemed not to exist and a reviewer may base a decision on missing information or inadequate records. The claimant’s argument that the treatment under review was palliative in nature was also rejected, given the lack of any indication in the provider’s records that a plan was in place to address the claimant’s pain. The Court observed that the absence of a reasoned approach to manage a claimant’s pain is a relevant factor for the WCJ to consider when determining the reasonableness and necessity of treatment. Lastly, the claimant’s reasoned decision argument was also rejected, since her argument went towards the weight of the evidence, rather than an actual reasoned decision argument.

 

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