Court Opinion

ID: 9650015
Source: CourtListenerOpinion
Date Created: 2023-08-23 15:19:38.76273+00
Date Added: 2024-06-11T18:12:17.081867
License: Public Domain

DISSENTING OPINION BY
JUDGE BUTLER
I respectfully dissent from the majority opinion in this matter. Because I agree that the Workers’ Compensation Appeal Board (Board) erred in reversing the order of the Workers’ Compensation Judge (WCJ) for a new utilization review, I would reverse the decision of the Board.
The purpose of the Workers’ Compensation Act as a whole is “to benefit the workers of this Commonwealth; therefore, its provisions must be liberally construed to effectuate its humanitarian objectives, and borderline interpretations are construed in the injured party’s favor.” Gillette v. Wurst, 594 Pa. 544, 554, 937 A.2d 430, 436 (2007). This principle must be applied not only to statutory provisions, but to all regulations promulgated under the Workers’ Compensation Act (Act).1
Section 306(f.l)(5) of the Act, 77 P.S. § 531(5), allows employers to challenge the reasonableness and necessity of services provided by medical care providers, subject to the procedures set forth in the Regulations, 34 Pa.Code §§ 127.1-127.755. Section 127.459 of the Regulations, 34 Pa. Code § 127.459, states in relevant part:
(b) The medical records of the provider under review may not be requested from, err supplied by, any source other than the provider under review.
(c) The provider under review, or his agent, shall sign a verification that, to the best of his knowledge, the medical records provided constitute the true and complete medical chart as it relates to the employe’s work-injury.
(Emphasis added).
Further, Section 127.464 of the Regulations, 34 Pa.Code § 127.464, 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 shall do the following:
(1) Determine whether the records were mailed in a timely manner.
(2) Indicate on the determination that the records were requested but not provided.
(3) Adequately document the attempt to obtain records from the provider under review, including a copy of the certified *550mail return receipt from the request for records.
(Emphasis added).
This Court has held that a WCJ has the jurisdiction to determine “issues of the adequacy of the [URO’s] pursuit of the Verification Form, the [URO’s] compliance with 34 Pa.Code § 127.464(b), and whether the provider complied with that section.” HCR ManorCare v. Workers’ Comp. Appeal Bd. (Bollman), 951 A.2d 1242, 1246 (Pa.Cmwlth.2008). Based upon the evidence, the WCJ may “uphold the determination based on failure to provide the records or vacate the determination and order that the records be sent to a reviewer for a URO determination on the merits of whether the treatment in question was reasonable and necessary.” Id. (quoting Gazzola v. Workers’ Comp. Appeal Bd. (Ikon Office Solutions), 911 A.2d 662, 665 (Pa.Cmwlth.2006)). On the facts of this case I believe it was entirely appropriate for the WCJ to order the records returned to the URO for a determination on the merits.
Here, there is no dispute that Claimant suffered a work-related injury to her back, that she received bilateral myoblock injections for pain relief from Ted D. Kosenske, M.D. at the Carlisle Regional Medical Center, that Dr. Kosenske executed the verification, or that the URO. timely received Dr. Kosenske’s records. The requisite verification, however, was not included in the timely submission to the URO. When the URO returned Claimant’s records to Dr. Kosenske requesting the verification, the signed verification was, for some unexplained reason, not forwarded to the URO in a timely manner. From an equity standpoint, I respectfully disagree with the Majority’s conclusion that Dr. Kosenske’s failure to provide the verification form is the same as providing no medical records at all, when: a) the records were provided, and b) Dr. Kosenske is not a party before the Court.
The parties at interest for our purposes are the Claimant and the Employer, and indeed the matter is before this Court on Claimant’s appeal. Under Section 127.459(b), however, Claimant was divested of any opportunity to cure this defect by forwarding the signed verification herself. Thus, through no fault of her own, Claimant was denied meritorious assessment of the necessity and reasonableness of her pain relief injections as the URO issued its determination pursuant to Section 127.464(a) indicating that the services reviewed were not reasonable and necessary. In reality, the URO did not review any services, but merely excused Employer on a perceived procedural technicality from compensating Claimant for pain relief treatment related to her work injury. According to the Majority, Claimant is not without recourse as Claimant may simply turn to another provider for the pain treatment at issue. The Majority, perhaps, misses the practical implications of the Board’s determination that the treatment at issue was not reasonable and necessary'. Employer may very well use this determination as a basis for refusing to pay for Claimant’s myoblock pain relief injections in the future. In my opinion, the result is contrary to the spirit of the Workers’ Compensation Act.
Moreover, I must also disagree with the Majority’s conclusion that there is no dispute that the URO in the present case followed the required procedures. Given that precise question, the WCJ recognized the fact that the URO received Claimant’s medical records in a timely manner, and that the regulations do not direct URO’s to return medical records that are substantively complete for lack of a verification form. Section 127.466 of the Regulations, 34 Pa.Code § 127.466, provides that: *551“Upon receipt of the medical records, the URO shall forward the records ... to a reviewer ...(Emphasis added). Here the URO failed to forward the records to a reviewer. Thus, the WCJ vacated the URO’s determination, and directed a determination on the merits. I agree with the WCJ’s decision as it is entirely consistent with the stated purpose of the Act. In my view, it was highly appropriate and within the WCJ’s discretion to order a meritorious assessment, the validity of which would of course be contingent upon verification of the records reviewed.
I would reverse the Board and affirm the WCJ.

. Act of June 2, 1915, PL. 736, as amended, 77 P.S. §§ 1 — 1041.4, 2501-2708.