Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Sexton v. Workers' Compensation Appeal Board

May 22, 2009

LINDA SEXTON, PETITIONER
v.
WORKERS' COMPENSATION APPEAL BOARD (FOREST PARK HEALTH CENTER), RESPONDENT



The opinion of the court was delivered by: Judge Pellegrini

Submitted: May 6, 2009

BEFORE: HONORABLE BONNIE BRIGANCE LEADBETTER, President Judge HONORABLE BERNARD L. McGINLEY, Judge HONORABLE DAN PELLEGRINI, Judge HONORABLE RENÉE COHN JUBELIRER, Judge HONORABLE ROBERT SIMPSON, Judge HONORABLE MARY HANNAH LEAVITT, Judge HONORABLE JOHNNY J. BUTLER, Judge.

OPINION

Linda Sexton (Claimant) appeals from a decision of the Workers' Compensation Appeal Board (Board) reversing the order of the Workers' Compensation Judge (WCJ) which ordered a new utilization review and granted the appeal of Forest Park Health Center (Employer). Finding no error in the Board's decision, we affirm.

Claimant suffered a work-related back injury in April 1999. Claimant sought treatment from Ted D. Kosenke, M.D. (Dr. Kosenke) and began receiving myoblock injections for pain relief in December 2004. Employer subsequently filed a utilization review petition seeking a determination as to whether the pain relief injections were reasonable and necessary.

The utilization review was assigned to the Utilization Review Organization (URO) of McBride & McBride Associates. On January 31, 2005, the URO requested Claimant's records from Dr. Kosenke. On February 10, 2005, it received the requested records but the records did not contain the required verification form signed by Dr. Kosenke. On February 15, 2005, the URO returned the records and asked that Dr. Kosenke resubmit them with the signed verification form. According to testimony given by Brett Miller (Director Miller), the Director of Health Information at Carlisle Regional Medical Center, Dr. Kosenke did execute the requested form, but the medical center failed to forward the signed verification, even after the February 15 request. Because the forms were not timely provided to the URO, on March 30, 2005, it issued a determination that the treatments were neither reasonable nor necessary.

Claimant then filed a petition for review of Utilization Review Determination with a WCJ. On March 20, 2006, the WCJ ordered that further utilization reviews be conducted for an assessment on the merits of whether the pain relief injections were reasonable and necessary. Employer appealed to the Board, which vacated the WCJ's decision and remanded the matter to the WCJ for a determination as to whether the URO followed proper procedure. After holding hearings on the matter and accepting deposition testimony, the WCJ concluded that under Section 127.459(c) of the Workers' Compensation Medical Cost Containment Regulations (Regulations), 34 Pa. Code §127.459, a verification form was required, but the Regulations did not direct a URO to return timely received records for a lack of verification. Because the URO in the present case returned the records solely for lack of a signed verification, the WCJ again ordered an assessment on the merits and awarded Claimant cost of litigation.

Employer then appealed that decision to the Board maintaining that the WCJ erred in ordering further utilization review because the failure to timely issue the verification form with the medical records to the URO was a failure to comply with the utilization review provisions. The Board agreed and reversed the WCJ's decision. Claimant then appealed to this Court.*fn1

Section 306(f.1)(6) of the Workers' Compensation Act (Act),*fn2 77 P.S. §531(6),*fn3 as implemented by 34 Pa. Code §127.464, provides the exclusive procedure for challenging the reasonableness or necessity of medical treatment and states that neither a workers' compensation judge nor the Board has jurisdiction to determine the reasonableness of medical treatment unless and until a report is issued. Section 306(f.1)(6)(iv) of the Act, 77 P.S. §531(6)(iv), provides that a petition for review of a URO determination is to be "filed within thirty (30) days after receipt of the report" and shall be decided by a judge who shall consider the URO report as evidence. Where a provider has failed to produce the medical records as requested by the URO, the request is not assigned to a reviewer, and no reviewer's report is written. See 34 Pa. Code §§127.464(a) and (c). Where that occurs, the reasonableness of the bills submitted are final and cannot be appealed to the WCJ. County of Allegheny v. Workers' Compensation Appeal Board (Geisler), 875 A.2d 1222 (Pa. Cmwlth. 2005).

On appeal, Claimant argues that the URO did not have the authority to return the medical records for lack of verification and it was correspondingly required to submit them to a reviewer to determine if the treatments covered by those bills were reasonable and necessary.

The procedures that a URO is to follow in securing medical records are set forth at 34 Pa. Code §127.464 which provides:

(a) If the provider under review fails to mail records to the URO within 30 days of the date of request of the records, the URO shall render a determination that the treatment under review was not reasonable or necessary if the conditions set forth in subsection (b) have been met.

(b) Before rendering the determination against the provider, a URO ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.