Theresa Skay v. Borjeson & Maizel LLC(WCAB) ___A.3D___ (Pa. Cmwlth. filed 5/10/22; reported 7/26/22) No 999 C.D. 2021.
As we know Employers have been in a quandary since the 2020 Commonwealth Court’s decision in Workers’ First Pharmacy Services, LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office (Gallagher Bassett Services) 225 A.3d 613 ( Pa. Cmwlth. 2020). In Workers’ First, the Commonwealth Court held that the Employer could not challenge treatment as inconsistent with diagnoses unless a Utilization Review had been requested. The reasoning was that if treatment was not causally related to the injury it would not be reasonable and necessary. However, this ignored case law noting that the Utilization Reviewer is to presume causation. Thus, we had a situation where Utilization Review had found wrist treatment reasonable although the only accepted injury was to the right ankle.
In Skay, the Court confirms longstanding precedent that an Employer is NOT responsible to pay for medical treatment that is NOT causally related to the work injury. Significantly, in Skay, Utilization Review was decided in 2015 and 2017 while a Petition to Review was decided in 2019 denying that a psychological condition and postural orthostatic tachycardia syndrome (POTS) should be added to the accepted work injury. Thus, in that case it was clearly established that certain diagnoses were not causally related to the work injury. This, of course, makes it clear that those diagnoses were NOT related. However, it is Claimant’s burden to establish a causal relationship of conditions not obviously related to the work injury by way of persuasive and reasoned medical opinion. It is especially well settled that an Employer may properly deny payment of medical treatment for psychological injury when only a physical injury has been accepted. King v. WCAB (Wendell H. Stone Co.), 572 A.2d 845 (Pa. Cmwlth. 1990).
Accordingly, Skay highlights the need to review medical bills carefully and ensure they are related to the ACCEPTED injury before paying regardless of Utilization Review. Like Skay, this is critical if the Judge has decided a Review Petition addressing the scope of injury.