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Warman v. Workers' Compensation Appeal Board6/13/2002
Louise Warman (Claimant) petitions for review of an order of the Workers' Compensation Appeal Board (Board) that affirmed the decision of the Workers' Compensation Judge (WCJ) denying Dr. Mark Clemente's (Provider) petition for review of a utilization review (UR) determination. We affirm.
On December 21, 1994, Claimant, at the age of 68, slipped and fell injuring her back, chest, and shoulder while working for Care Unlimited, Inc. (Employer). Claimant began treating her injuries with Provider, a chiropractor, on January 13, 1995. She continued to treat with Provider through March 1995, when she returned to modified work. Claimant receives partial disability benefits and continues to treat with Provider.
Employer filed a request for a UR determination on November 3, 1997, contesting all of Provider's chiropractic treatment of Claimant after September 15, 1997. Employer's UR request was assigned to Alan Horwitz, D.C., also a chiropractor, who determined that Provider's care was neither reasonable nor necessary after September 15, 1997. Dr. Horwitz concluded that a course of active rehabilitation should have been provided to Claimant for a period of six months, at which time a transition to a home-based exercise program should have occurred. Provider filed a petition to review the UR determination.
In addition to the UR report by Dr. Horwitz, Employer submitted a narrative report prepared by Constance Haber, D.C. Dr. Haber examined Claimant at the request of the state workers' insurance fund. Dr. Haber testified that she performed a physical examination of Claimant and reviewed Provider's treatment records. She opined that Provider's treatment of Claimant since September 15, 1997 was not reasonable and necessary. Dr. Haber noted that she could not find any evidence of objective improvement in Provider's records. Additionally, she did not find specific goals listed in the records or evidence that a controlled withdrawal of care had been attempted.
Claimant testified that, when she began treating with Provider, she had difficulty walking to Provider's office from his parking lot. She also testified that she had problems with dizziness and maintaining her balance. According to Claimant, after she began treatment with Provider her balance began to improve and she was not as dizzy or light-headed. Claimant believes that Provider's treatment has helped her regain her "functioning life" and that continued treatment with him would be beneficial.
Claimant acknowledged that her symptoms have increased. Reproduced Record (R.R.) at 247a. She explained that she wished to continue treating with Provider, since his treatment will help her to continue working. Although she was continuing to treat with Provider, she still had pain in her shoulders and at the base of her neck.
Provider testified that as a result of numerous clinical obstacles that Claimant was experiencing, including severe bruising and disorientation, he was unable to begin aggressively treating Claimant until one year after her injury. Provider explained that once he was able to begin treatment, it was primarily passive in nature. Provider maintained that his treatment of Claimant is reasonable and necessary. In Provider's opinion, as a result of the treatment, Claimant achieved a 55 to 60 percent recovery from her work injuries. Provider acknowledged, however, that Claimant's condition has deteriorated. R.R. at 239(a). He believes that her deterioration resulted from her decreased ability to visit his office for treatment during the winter months.
The WCJ denied Provider's petition and concluded that his treatment was not reasonable or necessary. The Board affirmed
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