The Commonwealth Court of Pennsylvania has held that a determination of certain treatment in the nature of prescription medications being not reasonable or necessary medical treatment is irrelevant in determining whether an injured worker’s death was causally related to the compensable work-related injury.

On December 2, 2011, the Commonwealth Court circulated an opinion written by Judge Brobson in the case of J.D. Landscaping v. Workers’ Compensation Appeal Board (Heffernan), 1866 C.D. 2010. The Defendant in the underlying litigation, J.D. Landscaping, petitioned the court to review the order of the Workers’ Compensation Appeal Board (WCAB), which affirmed the decision of the Workers’ Compensation Judge (WCJ) granting a fatal claim petition filed by Casey Lynn Heffernan (claimant) requesting benefits as a result of the death of her father, James Heffernan (decedent).

By way of background, decedent incurred a work-related injury while working for the employer on July 12, 2002. The injury was initially recognized as a “lower back strain.” Ultimately, the injury was expanded to include a herniated disc at L4-5.

On March 5, 2006, the employer filed a Utilization Review (UR) request, challenging the reasonableness and necessity of all treatment provided to decedent by George Rodriguez, M.D., on or after February 15, 2007. By UR determination issued June 4, 2007, a conclusion was made that treatment provided by Dr. George Rodriguez, including prescriptions for fentanyl, was neither reasonable nor necessary from February 15, 2007, into the future.

The decedent attempted to fill his prescription, but the pharmacy refused to fill the order based on the UR results. Decedent called Dr. George Rodriguez who told decedent he should come to the office the next day to see his sister, Dr. Daisy Rodriguez. Despite knowing the results of the prior UR, Dr. Daisy Rodriguez wrote the identical prescription that was found to be unreasonable and unnecessary in the UR determination.

On November 17, 2007, the claimant filed a fatal claim petition against the employer, alleging that the decedent died of multiple drug intoxication on June 18, 2007. It was agreed by the parties that the decedent died from prescription drugs prescribed for him as a result of his work injury, however, that the employer was not responsible for the payment of those drugs from February 15, 2007, and ongoing into the future based upon the June 4, 2007, UR determination. It was further agreed that the decedent died as a result of an accidental overdose, in excess of the amount prescribed for him for the work injury.

By order dated October 8, 2009, the WCJ granted the claimant’s fatal claim petition finding that “Decedent’s death was causally related to an accidental overdose of pain medications, primarily fentanyl based medications, which were prescribed for Decedent’s work-related back injury on July 12, 2002.” The WCJ found that the medications prescribed by Dr. George Rodriguez and Dr. Daisy Rodriguez were prescribed for the claimant’s work-related back injury. The WCJ found that the treatment of Dr. Daisy Rodriguez was never the subject of a request for utilization review and that the prior UR determination regarding Dr. George Rodriguez’s treatment had no bearing on the treatment rendered to the decedent by Dr. Daisy Rodriguez.

An appeal was taken to the Workers’ Compensation Appeal Board. The employer argued that the WCJ erred in granting the fatal claim petition because the decedent died as a result of the accidental overdose on prescription pain medication found to be not reasonable or necessary by the underlying UR determination. By order dated August 13, 2010, the Board affirmed the WCJ’s decision. The Board found that the UR determination applied only to treatment rendered by Dr. George Rodriguez and was not dispositive because Dr. Daisy Rodriguez prescribed the medication that caused the decedent’s death.

On appeal to the Commonwealth Court, the employer argued that the Board and the WCJ erred in determining that Dr. Daisy Rodriguez’s treatment is not subject to the June 4, 2007, UR determination. The employer acknowledged that UR determinations are provider specific but maintained that the underlying UR determination should nevertheless apply to Dr. Daisy Rodriguez’s treatment as well. The Commonwealth Court stated, “Regardless of whether the June 4, 2007 UR Determination applies to Dr. Daisy Rodriguez’s treatment, we disagree that the Board and WCJ erred in granting Claimant’s Fatal Claim Petition.”

The Commonwealth Court noted that the employer was contending, in essence, that there can be no causal relationship between the decedent’s death and a work-related injury where decedent dies as a result of medical treatment deemed by a UR determination to be neither reasonable or necessary. The court found that the employer misconstrued the import of a utilization review determination.

The Commonwealth Court is clear in indicating that the issue of causation is separate and distinct from the reasonableness and necessity of medical treatment. The Commonwealth Court specifically found that “The June 4, 2007 UR Determination, which concerns only reasonableness and necessity, is irrelevant in determining whether Decedent’s death was causally related to Decedent’s work-related injury.” As such, the award of fatal claim benefits was affirmed. 

What It Means to You

There are two main lessons in this tragic case: the inquiry on a fatal claim petition solely involves whether the death was causally related to the work injury, which is separate and distinct from the issue of reasonableness and necessity; and, after receiving a favorable utilization review determination, the wary adjuster should be vigilant for an immediate change in the treating physician.

While it appears from the facts of this case that the decedent was in essence “doctor shopping” in order to find a physician who could write the same prescription medications that were earlier found to be not reasonable or necessary, the courts have nonetheless failed to place any significance on these facts in deeming that the decedent’s death was related to the work injury. Any switch of treatment to a new physician immediately following a successful utilization review should be immediately challenged.