Injured Worker Wins Pre Approval for Nursing Home Care

On August 8, 2008, Fred Howe (name changed for this blog) suffered a work injury to the left ankle while loading a lawn mower onto a trailer. He was employed by Strange & Associates. The workers’ compensation carrier, Selective Insurance Company, accepted liability for the work injury by issuing a Notice of Compensation Payable.

Due to the work injury, the injured worker developed symptoms and pain in his left ankle and leg, radiating up the leg. He also developed numbness and swelling, jerking in his sleep, headaches, and muscle spasms. Over time, these symptoms began spreading to the right side. Medical treatment included pain medications, a brace/splint, and spinal cord stimulator. These symptoms were aggravated by activity, rest, or inactivity. The injured worker required frequent hospitalizations due to these symptoms. He also received medical treatment from his family doctor, Dr. Charles Lowe. Dr. Lowe felt FH suffered from reflex sympathy disorder (RSD) and/or complex regional pain syndrome. In early 2013, different living arrangements were being pursued to help with self-care and to avoid hospitalizations. He had also developed a sore on the back of his left thigh, which would not heal and required home health assistance.

In January, 2013 we filed a prospective Utilization Review Request, asking that an independent doctor decide whether nursing home care would be appropriate treatment for his work injury. Dr. Paul Doghramji of Margroff Review Services, stated that patients with RSD are known to become highly dependent on others for their activities of daily living, and need an assisted living environment. Dr. Doghramji felt that placement in a nursing home was reasonable and necessary due to Dr. Lowe’s documentation of great difficulty in performing activities of daily living. Winning the prospective utilization review grants him legal pre approval of the treatment and the treatment must immediately be paid for by the workers’ compensation carrier when the treatment commences. Even if the carrier appeals the unitization review determination, they must pay for the treatment while the case is on appeal.

If you would like to speak personally to us about your Pennsylvania or Harrisburg work related accident or injury, or benefits, please fill out our confidential online contact form or call Calhoon and Kaminsky P.C., toll-free at 1-877-291-WORK (or 9675). Whether you wish to begin the claims process, or are encountering problems and concerns while on workers’ compensation, Calhoon and Kaminsky P.C., will fight to obtain the benefits you are entitled to receive, guide you in the right direction, and obtain a fair settlement if that is in your best interest. There is no fee for us answering your questions or advising you of your rights so you head in the right direction.