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Employer may have to cover compound creams

Posted On: Nov. 2, 2020 12:01 PM CST


An employer may be on the hook for $4,827.56, plus interest, in costs for a pain-relieving compound cream dispensed to an injured worker whose claim it accepted and whose pharmacy order went without a utilization review request, a judge in Pennsylvania ruled Friday.


In 2017, a worker with a fractured left ankle was prescribed a compound cream consisting of at least six elements, and was instructed to apply the compound cream to the “affected area” two to four times a day, as needed, per treatment for the accepted workers compensation injury, according to documents in Omni Pharmacy Services, LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office (American Interstate Insurance Company), filed in the Commonwealth Court of Pennsylvania in Harrisburg.


Omni Pharmacy Services LLC dispensed the compound cream in 2018 and submitted three invoices to the employer — Stitzer Crane Services Inc. — for a total of $6,081. The employer denied payment of all invoices, stating it was not liable for the treatments.


The pharmacy then filed fee review applications, which resulted in determinations in favor of pharmacy, directing the employer to pay repriced invoices in the amount of $4,827.56, plus interest at the rate of 10% annually, calculated from the date payment on each bill was due, according to documents.


The employer appealed, requested hearings to contest the determinations, arguing that the “bills have been denied on the issue of causation,” among other claims, according to documents. The pharmacy argued that the employer “asserted its causation issue without presenting any evidence that the compound cream was not prescribed for treatment of Claimant’s work injury.” Neither Employer nor Pharmacy presented testimonial evidence, according to documents.


A hearing officer concluded “that there is a dispute… pertaining to the causal relationship of the prescribed compound cream and the accepted work injury” and vacated the fee review determinations that directing the employer to cover the cream, according to documents.


The pharmacy appealed, asserting that the hearing officer erred, arguing that the employer “has accepted liability for Claimant’s work injury, but it did not seek utilization review of the compound creams as neither reasonable nor necessary to treat Claimant’s work injury,” according to documents.


In turn, the employer argued that case law — Workers’ First Pharmacy Services, LLC v. Bureau of Workers' Compensation Fee Review Hearing Office — regarding a compound cream prescribed to an injured worker for an ailment unrelated to a worker’s injury was not accepted in court as part of the claim, according to documents.


The Pennsylvania court ruled Friday that the previous case is not the same as the current, in which the employer accepted the claim and the cream was prescribed as a result of that injury. The court wrote vacated the hearing officer’s dismissal of the payments due and remanded the matter “for a decision on the merits of the fee review determinations.”