October 24, 2013
On June 2, 2003, Uriah Graham, while working for the Commonwealth of Pennsylvania State Correctional Institute in Camp Hill, PA, was climbing up a ladder to his post when his arm suddenly went numb and he fell twenty feet to the concrete below. Because the workers’ compensation insurance company would not pre-approve the purchase of the prescription for the scooter, we filed a prospective Utilization Review for a motorized scooter as prescribed by Dr. Donald Kovacs. The Utilization Review denied treatment, finding it unreasonable and unnecessary. So we filed a Petition to Review to the Utilization Review Determination and the appeal was assigned to Worker’s Compensation Judge Brian Eader who strongly disagreed with the Utilization Review and granted the reasonable and necessary motorized scooter based on the following factors and testimony:
Due to his tragic fall at work, Mr. Graham suffered injuries to both ankles, both knees, his back, his head and a broken bone under his left kneecap. Mr. Graham has undergone many surgeries, including lumbar decompression laminectomy and discectomy surgery at L3, L4 and L5. Mr. Graham experiences excruciating pain in his lower extremities as a result of his injury. These include stabbing pain, numbness, tingling and a fire sensation in both of his legs, and this pain in his left legs remained even after his surgeries. Mr. Graham’s condition has worsened over time. He feels as if someone is sawing through his ankle and gouging something in his right knee and twisting at all times.
Due to this intense pain, Mr. Graham puts more weight on his right leg, causing overcompensation. Mr. Graham has difficulty standing for more than 10 minutes and walking more than 300 feet without rest and requires the use of a cane or other assistive device. Mr. Graham put a pool and hot tub on his property so he can engage in less joint stressful exercises and improve his quality of life, but cannot access these because of a steep hill on his property. Mr. Graham has gained 60 pounds since his injury due to his inability to mobilize and exercise. He attempts to conduct daily life activities, and go on outings, for example, the Renaissance Faire, but these activities cause unbearable pain from walking and not being able to keep the swelling in his knees at bay. Mr. Graham believes the motorized scooter will drastically improve his quality of life, as he would be able to keep his knee swelling down, move around more easily, go back to normal daily activities like grocery shopping, and traverse the hill in his yard to be able to use the pool and hot tub for exercise.
Judge Eader found Mr. Graham’s testimony credible, unequivocal, supported by Doctor testimony and true as fact. He further evaluated the Utilization Review Determination and weighed its findings against the significantly more credible reports from Mr. Graham’s treating physicians, Dr. Kovacs, Dr. Keller and Appalachian Orthopedic Center. The Utilization Reviewer, Dr. Richless, found the motorized scooter to be unreasonable and unnecessary while ignoring medical evidence that supports that Claimant has extreme pain and discomfort, difficulty walking more than 300 feet, walks with a gait, uses an assistive device, and treating physician’s recommendations regarding Mr. Graham’s need for the motorized scooter.
Judge Eader also found the testimony of the Independent Medical Examination physician, Dr. Kline, to be incredible, unpersuasive and rejected it his recommendation. Dr. Kline found Mr. Graham was not fully recovered and at maximum medical improvement, and noted tenderness over the postoperative lumbosacral scar, left sacroiliac region and with palpation to the medial joint of the lumbosacral spine. Dr. Kline only saw Mr. Graham for 10 minutes, in which time it is unsure if he would have been to see if Mr. Garham struggled to walk more than 300 feet, and yet he found the motorized scooter unreasonable and unnecessary. Judge Eader strongly disagreed with Dr. Kline’s opinions finding them unreliable and deficient, and rather, as the law dictates, weighed the opinions of Mr. Graham’s treating physicians more heavily.
Judge Eader found a myriad of evidence in support of the reasonable and necessity of the motorized scooter for Mr. Graham. This included Mr. Graham’s testimony and opinions of Dr. Keller, Dr. Kovacs and Appalachian Orthopedic Center. All of Mr. Graham’s treating physicians concurred Mr. Graham suffered from chronic back pain as a result of his work injury and that even after several surgeries he still has difficulty walking, uses a cane and cannot participate in normal daily activities. All physicians agreed and had medical evidence to support the necessity of the motorized scooter for Mr. Graham.
The Defense was not able to meet their burden of proof to show that the treatment in question was unreasonable or unnecessary as they could not present credible evidence that could refute the testimony of Claimant’s treating physicians, and therefore Judge Eader found the scooter to be reasonable and necessary medical treatment relating to Mr. Graham’s work injury. Judge Eader ordered the defense to pay for the $4,725.00 motorized scooter and the costs of litigation.
