Court Opinion

ID: 4383506
Source: CourtListenerOpinion
Date Created: 2019-04-03 13:37:36.16719+00
Date Added: 2024-06-11T14:50:07.173982
License: Public Domain

IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Crozer Chester Medical Center,                 :
                        Petitioner             :
                                               :
               v.                              :    No. 648 C.D. 2018
                                               :    Argued: March 12, 2019
Bureau of Workers’ Compensation                :
Fee Review Hearing Office (Laundry             :
Owners’ Mutual Liability Insurance),           :
                        Respondent             :

BEFORE:        HONORABLE ROBERT SIMPSON, Judge
               HONORABLE MICHAEL H. WOJCIK, Judge
               HONORABLE CHRISTINE FIZZANO CANNON, Judge

OPINION NOT REPORTED

MEMORANDUM OPINION
BY JUDGE SIMPSON                               FILED: April 3, 2019

               This case involves an appeal under the trauma center exemption from
the medical fee caps in the cost containment provisions of the Workers’
Compensation Act (Act).1 The Crozer Chester Medical Center (Provider) petitions
for review of an order of Workers’ Compensation Fee Review Hearing Officer
Thomas Kuzma (Hearing Officer) that vacated an administrative determination by
the Bureau of Workers’ Compensation’s Medical Fee Review Section (Bureau),
concluding that Provider was entitled to $84,659.54 under the trauma center
exemption for medical services provided to David Parker (Claimant). In vacating
the Bureau’s fee review determination, Hearing Officer determined Claimant did not
suffer an immediately life-threatening or urgent injury. Therefore, Hearing Officer

      1
          Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §§1-1041.1, 2501-2710.
ruled that Provider was not entitled to any more than the $12,402.46 already tendered
by Laundry Owners’ Mutual Liability Insurance (Insurer).

             Provider contends Hearing Officer erred in vacating the Bureau’s fee
review decision and by determining that Provider’s services did not qualify as
trauma services for purposes of the trauma center exemption. For the reasons that
follow, we are constrained to affirm.

                                   I. Background
             In his decision, Hearing Officer noted that the central issue in
Provider’s appeal was whether the treatment provided to Claimant was for an
immediately life-threatening or urgent injury, such that Provider is entitled to
reimbursement at 100% of the usual and customary charges, and not limited by the
medical fee caps. See Section 306(f.1)(10) of the Act, 77 P.S. §531(10) (provider
entitled to its usual and customary charge for acute care in an acute care facility,
accredited as a Level I or Level II trauma center, of a patient with immediately life-
threatening or urgent injury).

                            A. Claimant’s Work Injury
             Hearing Officer found the following facts. On January 22, 2016,
Claimant suffered work-related injuries when he started a farm tractor that he did
not know was in gear. The tractor pushed him to the ground and ran over his right
foot. Emergency Medical Services (EMS) personnel arrived at the scene and made
the following triage assessment: (a) Claimant’s chief complaint was right-foot
fracture, confirmed when EMS removed Claimant’s boot, Claimant had a good pulse

                                          2
and motor sensation; (b) Claimant also complained of right-arm pain, he denied
head, neck, or back pain; (c) Claimant remained alert, he did not lose consciousness,
he gave verbal consent for transport; (d) Claimant’s Glasgow Coma Scale was 15
(alert, responsive);2 (e) Claimant’s airway was patent and respiration was normal;
(f) Claimant’s cardiovascular, neurological and mental status assessments were
normal; (g) Claimant’s pelvis was stable to flexion/compression; and (h) Claimant’s
head, neck and chest were unremarkable, his abdomen was non-tender and no
abnormalities of the back were detected.

              EMS transported Claimant, without lights or sirens, from the accident
scene to Provider even though another hospital was closer. Upon arrival, Claimant
was awake and oriented. He answered questions. Claimant’s admitting physician,
Dr. Mohammed H. Budier, noted Claimant’s chief complaints were pain in the right
foot, right groin and right side of his chest. Vital signs were normal. Claimant had
tenderness as to the right ribs, superficial abrasions, tenderness of the right pelvis,
and a deformity of the right foot, with normal vascular exam, movement and
sensation. Subsequent diagnostic tests were ordered.

              Claimant’s chest X-ray read as normal. Computerized tomography
(CT) scans of Claimant’s head and cervical spine were negative. A FAST (focused
assessment with sonography in trauma) exam showed no signs of internal abdominal
or pelvic hemorrhage. However, a CT scan of Claimant’s pelvis showed a fracture

       2
        The Glasgow Coma Scale measures a patient’s level of consciousness. See Reproduced
Record (R.R.) at 41a. A Glasgow Coma Scale of less than 14 requires transport to a trauma center
under Step One of the American College of Surgeons’ (ACS) Field Triage Guidelines. R.R. at
39a.

                                               3
of the superior pubic ramus of the pelvis. An X-ray of Claimant’s right foot/ankle
revealed a homolateral Lisfranc fracture/dislocation and an oblique fracture through
the second metatarsal shaft.

             Provider’s Orthopedics Department (Orthopedics) also evaluated
Claimant. It noted Claimant’s metatarsal shafts were tenting the skin with blanching
of the skin. Orthopedics expressed concern regarding neurological skin compromise.
The same day, Dr. Evan Bash, an orthopedic surgeon, performed emergency surgery
in the nature of an open reduction internal fixation of the Lisfranc fracture/
dislocation and second metatarsal shaft fracture.

             Claimant’s superior pubic ramus fracture did not require surgical
intervention. Provider discharged Claimant two days later with post-discharge
instructions to follow up with Orthopedics for hardware removal. The record did
not indicate that Claimant needed follow-up treatment for the superior pubic ramus
fracture.

               B. Provider’s Charges; Fee Review Determination
             In March 2016, Provider billed Insurer $97,062 for the treatment it
rendered Claimant from January 22 through 24, 2016. Provider stamped the bill as
“trauma.” See Reproduced Record (R.R.) at 3a-4a. In response, Insurer issued
Provider an Explanation of Reimbursement indicating the diagnosis related group
amount due Provider as $12,402.46. Insurer reasoned that the medical fee caps
limited what Provider could charge.

                                         4
             In April 2016, Provider filed a timely application for fee review under
Section 306(f.1) of the Act, 77 P.S. §531, challenging Insurer’s payment. In its
response to a request for information from the Bureau, Insurer stated that the
ambulance record showed no lights or sirens were used and Claimant remained
awake and communicating. Claimant reported only an injury to his foot, and he did
not lose consciousness.

             In July 2016, the Bureau circulated its fee review determination. The
Bureau determined Insurer owed Provider $84,659.54, plus interest. The Bureau
further determined Provider’s documentation met the guidelines outlined in Section
127.128 of the Workers’ Compensation Medical Cost Containment Regulations
(MCC Regulations), 34 Pa. Code §127.128. Therefore, the Bureau concluded
Provider was entitled to reimbursement at 100% of the usual and customary
charges/rates.

                          C. Hearing Officer’s Decision
             Insurer filed an appeal in the nature of a Request for Hearing to Contest
Fee Review Determination. R.R. at 15a-16a. In the proceeding before Hearing
Officer, Insurer submitted into evidence several Bureau documents setting forth the
procedural history of the case, the EMS records, a report from Dr. John Curtis
(Insurer’s Physician), a full-time emergency room (ER) physician in New England,
an independent medical evaluation (IME) report from Dr. Steven Boc (IME
Physician), and a copy of the applicable American College of Surgeons’ (ACS) Field
Triage Guidelines (Triage Guidelines), dated 2011.

                                          5
             In opposition to Insurer’s appeal, Provider submitted, among other
items, two reports from Dr. Wassim Habre (Provider’s Physician), a trauma and
critical care surgeon employed by Provider. He is board certified in general and
critical care surgery.

             Hearing Officer found Insurer’s Physician’s report and testimony to be
credible and persuasive, with the exception of his speculation that EMS transported
Claimant to Provider because it was the closest hospital. Hr’g Officer’s Op., 4/9/18,
Finding of Fact (F.F.) No. 25. Hearing Officer found Insurer’s Physician well
qualified to discuss the issues in Provider’s appeal. Id. Hearing Officer also found
that the evidence supported Insurer’s Physician’s report and testimony. Id.

             Insurer’s Physician is a full-time ER physician at two hospitals in New
England that carry a trauma designation.        He is board certified, but not in
Pennsylvania, in emergency medicine and medical toxicology.            F.F. No. 21a.
Insurer’s Physician performed a review on Insurer’s behalf and authored a February
2017 report. F.F. No. 21b. He reviewed the EMS records, Provider’s medical
records, and the 2011 Triage Guidelines. Id. Insurer’s Physician also reviewed IME
Physician’s report and Provider’s Physician’s first report. Id.

             Insurer’s Physician made the following statements.         There is no
indication in the EMS records that EMS personnel concluded that Claimant needed
to be taken to a trauma facility. F.F. No. 21c. Claimant did not meet the Triage
Guidelines for a trauma center referral from the field. F.F. No. 21d. There is nothing
in the ER intake records indicating Claimant faced an immediately life-threatening

                                          6
or urgent injury based upon the Triage Guidelines. F.F. No. 21e. Although
Orthopedics expressed concern about a neurovascular skin compromise, neither the
EMS records nor the ER intake records indicate that a neurovascular compromise
occurred. Id. To the contrary, the location of the injury (right foot) and normal
pulses noted before and after Claimant’s surgery indicated that a neurovascular
compromise would not be expected. Id.

            Claimant’s fracture was not a life-threatening or urgent injury based on
the Triage Guidelines. F.F. No. 21f. Although surgical referral and reduction is
necessary to prevent arthritis and chronic pain, a Lisfranc fracture is not a limb-
threatening injury and commonly presents to non-trauma centers for management.
Id.

            Further, a superior pubic ramus fracture is a relatively common and
non-surgical injury. F.F. No. 21g. Such a fracture does not fit the Step Two ACS
triage category of a pelvis fracture. Id. Here, Claimant did not complain of pain to
the pelvis or abdomen. Id. EMS noted that Claimant’s pelvis was stable to
flexion/compression. Id. As such, there was no clinically apparent pelvis fracture,
and no concern about pelvis stability. Id. Rather, Claimant’s pubic ramus fracture
was discovered only after a CT scan. Id.

            Insurer’s Physician also stated that Claimant’s right-foot injury was not
a crush injury as referenced in Step Two of the Triage Guidelines. F.F. No. 21h.
The external exams did not note any bruising, laceration, or any real evidence that

                                           7
Claimant’s right-foot injury was the result of a crush. Id. The fracture/dislocation
could easily have occurred when the tractor pushed Claimant to the ground. Id.

                Insurer’s Physician also disputed Provider’s Physician’s initial report
on several grounds. F.F. No. 21j. Provider’s Physician described the mechanism of
injury as a tractor running over the right side of Claimant’s body. Id. However,
Claimant never indicated to EMS or ER personnel that the tractor ran over anything
more than Claimant’s right foot. Id. In addition, the clinical findings do not support
a belief that the tractor ran over the right side of Claimant’s body. Id.

                Insurer’s Physician also noted that Provider’s Physician incorrectly
stated that EMS personnel activated a Level II trauma alert upon arrival at Provider
at 11:40 a.m.       Id.   Insurer’s Physician also opined that Provider’s Physician
improperly relied upon a study published in a medical journal to indicate that an
impending neurovascular compromise is a potential limb-threatening injury. Id.
The study was a small study involving seven patients; none of them had Lisfranc
injuries. Id.

                Insurer’s Physician also disputed Provider’s Physician’s suggestion
that Claimant, 41 years old, is at an age where pelvic fractures are almost always
associated with severe trauma requiring massive force, such as motorcycle crashes
or crush injuries. Id. To the contrary, the EMS and ER records do not indicate that
Claimant suffered external trauma. Id.

                                            8
             Insurer’s Physician also disagreed with Provider’s Physician’s
statement that although Claimant’s pelvic injury did not require surgical
intervention, it would require long-term rehabilitation and pain management. Id.
Insurer’s Physician pointed out there is nothing in the record indicating Claimant
requires long-term rehabilitation and pain management because of his superior pubic
ramus fracture. Id.

             Hearing Officer also credited IME Physician’s report with respect to its
conclusion that the records IME Physician reviewed, in conjunction with his
December 2016 IME of Claimant’s work injury, showed no evidence of
compartment syndrome or neurovascular structural damage. F.F. No. 26. IME
Physician is a board certified podiatrist at the Foot and Ankle Center of Philadelphia.
F.F. No. 22a.

             As noted above, Hearing Officer rejected Provider’s Physician’s two
reports as not credible or persuasive. F.F. No. 24. Hearing Officer observed that
Provider’s Physician’s reports were not consistently based upon the evidence of
record. F.F. No. 24a. For example, the reports misstated the mechanism of
Claimant’s injury as a tractor running over the right side of Claimant’s body, as
compared to his right foot. Id. Provider’s Physician’s reports also alleged that
Claimant suffered a crush injury to the right side of his body, including the chest,
abdomen, and pelvis without explaining why the corrective treatment Provider
administered to Claimant on the date of injury consisted primarily of treatment for
the right-foot injury, identified by EMS as Claimant’s chief complaint.             Id.
Provider’s Physician’s reports also stated that Claimant’s superior pubic ramus

                                          9
fracture, detected on the CT scan, required long-term rehabilitation and pain
management. Id. Hearing Officer noted that the record did not support that
conclusion. Id.

             Hearing Officer also agreed with Insurer’s assessment that Provider’s
Physician’s reports confirm that his focus was on things that could have possibly
been wrong with Claimant once Provider performed further testing and evaluation.
F.F. No. 24b. In other words, Provider’s Physician’s reports were based more on
speculation and hypothetical problems than on the objective information available
at the time of Claimant’s initial assessment by the EMS and Provider’s ER intake
unit. Id.

             Ultimately, Hearing Officer found that the evidence did not support a
conclusion that EMS personnel transported Claimant to Provider because his injury
had been deemed immediately life-threatening or urgent. F.F. No. 27. Therefore,
Hearing Officer found that Claimant did not sustain an immediately life-threatening
or urgent injury for purposes of the trauma center exemption under the Act. F.F. No.
28.

             Consequently, Hearing Officer determined that Insurer proved by a
preponderance of the evidence that Claimant did not sustain an immediately life-
threatening or urgent injury on January 22, 2016, such that Provider should not be
reimbursed beyond the $12,402.46 already tendered. Conclusion of Law No. 4. In
short, Claimant’s injury did not meet the criteria under the Triage Guidelines for
transport to a trauma center at the time of Claimant’s initial assessment.

                                         10
              Accordingly, Hearing Officer vacated the Bureau’s fee review
determination. In particular, Hearing Officer stated: “Provider is not entitled to
reimbursement at 100% of usual and customary charges for the care provided
Claimant on January 22 through January 24, 2016.” Hr’g Officer’s Order, 4/9/18.
Provider petitions for review.3

                                        II. Discussion
                                        A. Argument
              Provider contends Hearing Officer erred in vacating the Bureau’s fee
review decision and by determining that Provider’s services were not trauma
services for purposes of the trauma center exemption. Provider contends Hearing
Officer’s determination that the services at issue did not qualify as trauma is not
supported by substantial evidence and does not comply with the Triage Guidelines
for determining whether the services were trauma related.

              More specifically, Provider asserts a determination of whether services
qualify as trauma for purposes of the trauma center exemption from the Act’s
medical fee caps is controlled by Section 306(f.1) of the Act, 34 Pa. Code §127.128,
and the Triage Guidelines. Section 306(f.1)(10) of the Act defines trauma as an
“immediately life-threatening or urgent injury.” 77 P.S. §531(10). Summarizing
Section 127.128 of the MCC Regulations, Provider asserts that acute care provided
in a trauma center is exempt from the Act’s medical fee caps where: (a) the injury

       3
          Our standard of review is limited to determining whether Hearing Officer’s findings are
supported by substantial evidence and whether Hearing Officer erred or violated a party’s
constitutional rights. Roman Catholic Diocese of Allentown v. Bureau of Workers’ Comp., Fee
Review Hearing Office (Lehigh Valley Health Network), 33 A.3d 691 (Pa. Cmwlth. 2011).

                                               11
is an immediately life-threatening or urgent injury and services are provided in an
accredited trauma center;4 (b) the patient is transported to the trauma center in

      4
          Section 127.128(a)-(d) of the MCC Regulations provides, in pertinent part:

               (a) Acute care provided in a trauma center or a burn facility is
               exempt from the medical fee caps, and shall be paid based on 100%
               of usual and customary charges if the following apply:

                 (1) The patient has an immediately life-threatening injury or
               urgent injury.

                 (2) Services are provided in an acute care facility that is one of
               the following:

                 (i) A level I or level II trauma center, accredited by the
               Pennsylvania Trauma Systems Foundation ….

                                               ****

               (b) Basic or advanced life support services, as defined and licensed
               under the [EMS] Act, [Act of July 3, 1985, P.L. 164, as amended,
               35 P.S. §§6921-6938] provided in the transport of patients to trauma
               centers or burn facilities under subsection (a) are also exempt from
               the medical fee caps, and shall be paid based on 100% of usual and
               customary charges.

               (c) If the patient is initially transported to the trauma center or burn
               facility in accordance with the [Triage Guidelines], payment for
               transportation to the trauma center or burn facility, and payments for
               the full course of acute care services by all trauma center or burn
               facility personnel, and all individuals authorized to provide patient
               care in the trauma center or burn facility, shall be at the provider’s
               usual and customary charge for the treatment and services rendered.

               (d) The determination of whether a patient’s initial and presenting
               condition meets the definition of a life-threatening or urgent injury
               shall be based upon the information available at the time of the
               initial assessment of the patient. A decision by ambulance personnel
               that an injury is life threatening or urgent shall be presumptive of
               the reasonableness and necessity of the transport to a trauma center

                                                 12
accordance with the Triage Guidelines; (c) the trauma determination is based on
information available at the time of the initial assessment of the patient; and (d)
trauma is presumed unless there is clear evidence of a violation of the Triage
Guidelines.

               Provider further asserts that Step Two of the Triage Guidelines
mandates that if there is a pelvic fracture or crushed extremity, the patient must be
taken to a trauma center. R.R. at 123a. Here, Provider argues, its Physician, who is
board certified in critical care and serves as its Associate Director of Trauma,
unequivocally reported that Claimant sustained a crush injury and a pelvic fracture
when the tractor ran over the right side of his body.

               Further, Step Three of the Triage Guidelines requires transport to a
trauma center if the accident results from an automobile striking a pedestrian or
bicyclist. Id. Here, a tractor ran over Claimant. Step Four defers to EMS provider
judgment for trauma transport. Id. The EMS judgment call will be upheld unless
there is a clear violation of the Triage Guidelines. Id.

               Provider asserts Hearing Officer erred in finding that the tractor only
ran over Claimant’s right foot rather than the entire right side of his body. ER
records confirm Claimant was tender over his ribs and had abrasions on his head,
tenderness of his right pelvis, right groin, and a right-foot fracture. Although

               or burn facility, unless there is clear evidence of violation of the
               [Triage Guidelines].

34 Pa. Code §127.128 (a)-(d) (citation omitted).

                                               13
Hearing Officer is free to believe Insurer’s Physician, Provider maintains there is no
support for Insurer’s Physician’s assumption, or Hearing Officer’s finding, that the
tractor only ran over Claimant’s right foot. A tractor running over Claimant’s right
foot would not cause abrasions to his head or tenderness of the right ribs and right
pelvis. Therefore, Provider argues a crush injury, a pelvic fracture and the EMS
judgment all warranted transport to a trauma center for Claimant’s serious and life-
threatening injuries.

               Provider further asserts that the following notes in its ER and treatment
records (as opposed to EMS records) contradict Hearing Officer’s findings and
conclusions: patient run over by tractor, R.R. at 174a (consultation); tractor ran over
patient’s right foot and knocked him to the ground; patient complaining of pain in
his right foot, right side of the chest and right groin, R.R. at 176a (discharge
summary); patient had leg and chest run over by tractor, R.R. at 178a (ER record);
pedal pulse diminished in patient’s right lower extremity, severe midfoot deformity
with skin tenting, R.R. at 179a (ER record); when patient fell to the ground, tractor
ran over the right side of his body, R.R. at 186a (trauma admission history), R.R. at
241a (trauma evaluation); when patient leaned over to start tractor, it leapt forward
running over his right foot and right side of his body, R.R. at 244a (trauma
evaluation).

               Provider argues that none of the above seven notes in its ER and
treatment records (as opposed to EMS records) supports Insurer’s Physician’s
assumption that the tractor only ran over Claimant’s right foot. Therefore, Provider
continues, Insurer’s Physician’s opinion, and Hearing Officer’s finding, is not based

                                           14
on substantial competent evidence. As such, Provider alleges Hearing Officer
clearly erred in finding and concluding that Provider’s services did not qualify for
payment under the trauma center exemption. Accordingly, Provider requests we
vacate Hearing Officer’s decision and remand for a reasoned decision based on the
competent evidence of record.

                                      B. Analysis
             In workers’ compensation cases, matters of credibility and evidentiary
weight are within the sole province of the fact-finder. Pittsburgh Mercy Health Sys.
v. Bureau of Workers’ Comp., Fee Review Hearing Office (U.S. Steel Corp.), 980
A.2d 181(Pa. Cmwlth. 2009). We will not reweigh the evidence or substitute our
credibility determinations for those of the hearing officer. Id. Further, it is irrelevant
whether the record contains evidence to support findings other than those made by
the fact-finder; the critical inquiry is whether there is evidence to support the findings
actually made. See A & J Builders, Inc. v. Workers’ Comp. Appeal Bd. (Verdi), 78
A.3d 1233 (Pa. Cmwlth. 2013). Moreover, we must view the evidence in a light
most favorable to the prevailing party and give it the benefit of all inferences
reasonably deduced from the evidence. Id.

             In a fee review proceeding, an employer or its insurer has the burden of
proving by a preponderance of the evidence that it properly reimbursed a provider
of medical services.      34 Pa. Code §127.259(f); Roman Catholic Diocese of
Allentown v. Bureau of Workers’ Comp., Fee Review Hearing Office (Lehigh
Valley Health Network), 33 A.3d 691 (Pa. Cmwlth. 2011). A decision by EMS
personnel that an injury is immediately life-threatening or urgent shall be

                                           15
presumptive of the reasonableness and necessity of the transport to a trauma center.
Roman Catholic Diocese. Significantly, “[t]he determination of whether a patient’s
initial and presenting condition meets the definition of an immediately life-
threatening or urgent injury shall be based on the information available at the time
of the initial assessment of the patient.” 34 Pa. Code §127.128(d) (emphasis added).

                       1. Right Foot v. Right Side of Body
             Here, the EMS records from the scene of the accident include the
following assessment: “[Patient] stated he was standing next to his tractor when he
started it not realizing it was in gear. The [patient] stated he was pushed to the
ground by it and the tractor ran over his [right] foot. [Patient] denies head, neck or
back pain also never had a [loss of consciousness].” R.R. at 31a. Claimant’s
admitting physician, Dr. Budier, stated in his discharge summary (with emphasis
added):

             This is a 41-year[-]old male who was brought to [Provider]
             from the scene of an accident. The patient said he was
             standing next to a farm tractor and leaned over and started
             the ignition. At that point, the tractor leapt forward
             running over the patient’s right foot and knocking him
             down to the ground. He was complaining of pain in his
             right foot, right side of the chest, and right groin.

R.R. at 176a.

             Similarly, IME Physician’s report includes the following history:
“[Claimant] stated that on 1/22/16 while at work he went to start a tractor while
standing next to it. He did not realize that it was in gear and he was pushed to the
ground by the tractor and it ran over his right foot.” R.R. at 24a (emphasis added).

                                         16
             At the hearing, Insurer’s Physician testified (with emphasis added):

             Q. When [Claimant] described the incident to both the
             ambulance personnel and later for his [IME], he stated that
             the tractor ran over his foot. Was there any indication in
             the medical records themselves, or in the history that he
             provided to any of his providers, that suggests that the
             tractor ran over the right side of his body?

             A. No. He seemed rather clear that the tractor ran over his
             foot. Incidentally, upon a secondary survey in trauma
             where, after ensuring that the patient is stable, a more
             complete exam is performed, they mentioned an abrasion
             on his head that was non-tender. But apparently to the
             examining physician then there were no external signs of
             trauma over the chest, over the abdomen, over the pelvis,
             over the leg. There was the deformity of the foot, an
             abrasion of the head, and some tenderness or pain in the
             right arm. But according to the medical record, there was
             not a scratch on his body.

             Q. If he ha[d] been run over by a tractor on the right side,
             would you have expected him to have other signs of injury
             on the right side of his body?

             A. I would. It seems to me that the injuries and physical
             findings are consistent with getting pushed over to the
             ground, perhaps landing on his side, maybe scraping, you
             know, on his forehead, but there was no evidence that he
             was actually run over, with the exception of his foot, by
             that tractor.

Notes of Testimony (N.T.), 8/18/17, at 34-35; R.R. at 88a-89a.

             Thus, competent medical evidence plainly supports Hearing Officer’s
finding that Claimant sustained a work injury when a tractor ran over his right foot.
Claimant’s injuries to the rest of the right side of his body are more consistent with
being knocked to the ground on his right side than being run over by a farm tractor.

                                         17
As noted above, any conflicts in the evidence were for Hearing Officer, as sole fact-
finder, to resolve. Pittsburgh Mercy.

                                     2. Crush Injury
             With respect to the crush injury to the right foot alleged by Provider’s
Physician, Insurer’s Physician stated in his report “[Claimant’s] foot was not
pulseless, crushed, degloved or mangled.          Thus, according to the [Triage
Guidelines], it was appropriate to transport him to the nearest medical facility.” R.R.
at 20a. In addition, IME Physician noted in his report that Claimant’s right-foot
injury showed no evidence of compartment syndrome or neurovascular structural
damage. R.R. at 26a.

             Consequently, Hearing Officer’s rejection of Provider’s Physician’s
testimony that Claimant suffered a crush injury is supported by substantial
competent evidence. See F.F. No. 24a.

                                 3. Pelvic Fracture
             With respect to Claimant’s superior pubic ramus fracture, diagnosed by
a CT scan, EMS records stated: “Pelvis Findings: Stable to flex/compression.” R.R.
at 33a. Further, Insurer’s Physician testified at the hearing that there was no
indication in the record that anyone who treated Claimant in the field knew, was
aware of, or even suspected Claimant had a pelvic fracture. N.T. at 50; R.R. at 104a.
Claimant did not complain of pain in his abdomen or pelvis. Id. As such, EMS
assessed the pelvis as stable. Id.

                                           18
              In addition, Hearing Officer correctly noted that Provider’s Physician’s
testimony that Claimant’s pelvic fracture required long-term rehabilitation or pain
management was not supported by the record. To the contrary, Claimant’s pelvic
fracture did not require any surgical intervention or follow-up treatment. F.F. No.
14a. Insurer’s Physician’s testimony supports this finding. See N.T. at 29-30; R.R.
at 83a-84a.

              Therefore, Insurer’s Physician’s opinion (that Claimant’s condition did
not warrant trauma transport under Step Two of the Triage Guidelines) provided
competent medical evidence supporting Hearing Officer’s rejection of Provider’s
Physician’s testimony (that Claimant’s incidental pelvic injury warranted trauma
transport under Step Two of the Triage Guidelines). Pittsburgh Mercy.

                                 4. EMS Judgment
              In Finding of Fact No. 27, Hearing Officer found that the evidence did
not support a conclusion that EMS personnel transported Claimant to Provider, a
trauma center, because they deemed his injuries life-threatening or urgent. This
finding is supported by substantial evidence. EMS records indicate transport was
accomplished with no lights or sirens. R.R. at 30a. EMS diagnosed Claimant’s
“Initial Patient Acuity” as “Lower Acuity (Green).” R.R. at 33a. Therefore, the
record does not support Provider’s contention that EMS personnel deemed
Claimant’s work injury to be immediately life-threatening or urgent for purposes of
the trauma center exemption in Section 306(f.1) of the Act, 77 P.S. §531.

                                          19
                                 III. Conclusion
            Provider’s arguments raise fairness and commonsense points.
However, the points run counter to the policy judgments made by the General
Assembly when it enacted the cost containment provisions of the Act, and the
regulations promulgated pursuant to them. For the above reasons, we conclude that
Hearing Officer’s decision that Claimant’s injuries were not immediately life-
threatening or urgent, for purposes of the trauma center exemption from the medical
fee caps, is supported by substantial evidence and is in accord with applicable law.
Accordingly, we affirm Hearing Officer’s order vacating the Bureau’s fee review
determination.

                                      ROBERT SIMPSON, Judge

                                        20
       IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Crozer Chester Medical Center,          :
                        Petitioner      :
                                        :
            v.                          :   No. 648 C.D. 2018
                                        :
Bureau of Workers’ Compensation         :
Fee Review Hearing Office (Laundry      :
Owners’ Mutual Liability Insurance),    :
                        Respondent      :

                                     ORDER

            AND NOW, this 3rd day of April, 2019, the order of the Bureau of
Workers’ Compensation Fee Review Hearing Office is AFFIRMED.

                                       ROBERT SIMPSON, Judge