CHARLESTON – The West Virginia Supreme Court of Appeals has ruled that a woman’s knee replacement surgery was not medically related or reasonably required to treat a Workers’ Compensation injury.

Angela B. Crites appealed the decision of the West Virginia Workers’ Compensation Board of Review, according to the Sept. 22 memorandum decision.

“The issue on appeal is whether a request from Lucas Pavlovich, M.D., for a right knee arthroscopy and the prescription medications Percocet 5/500, Vicodin 5/500, and Ultram 50 mg for post-operative pain, as well as unicompartment knee replacement surgery, is medically related and reasonably required to treat the compensable injury,” the decision states. “The claims administrator determined that neither the surgeries nor the medications are necessary on November 12, 2015.”

The Office of Judges affirmed the claims administrator’s decision on June 2, 2016. The Board of Review affirmed the Order of the Office of Judges on Nov. 9, 2016. 

Crites, a plant worker for Armstrong Hardwood Flooring Company, injured her right knee at work on April 5, 2013, when she stood up after kneeling.

On April 12, 2013, Crites sought treatment at Elkins Express Care for her injury. An x-ray of the right knee demonstrated mild osteoporosis and mild degenerative arthritis. Crites was examined and diagnosed with bursitis of the knee. She was given a wrap and was provided instructions to take anti-inflammatory medications.

In June 2013, Crites was examined at Tygart Valley Orthopedics and she described the injury and denied prior knee problems. Pavlovich recommended an MRI of the knee to rule out a possible medial meniscus tear versus an articular cartilage injury.

The MRI revealed one degenerative cartilaginous delamination in the medial and lateral knee compartments and two small knee joint effusions, a Baker’s cyst and likely ganglion cyst between the anterior cruciate ligament and posterior cruciate ligament. Pavlovich reviewed the MRI and confirmed a medial meniscus tear. He recommended proceeding with a diagnostic arthroscopy.

The claims administrator denied authorization for arthroscopic surgery on Jan. 23, 2014.  In another decision dated April 11, 2014, the claims administrator held the claim compensable for bursitis of the right knee.

Pavlovich performed the surgery on Crites on May 9, 2014, and confirmed she suffered from a right knee meniscus tear. At the time of surgery, Pavlovich completed a diagnosis update asking that the conditions of internal derangement and medial meniscus tear be added to the compensable conditions in the claim.

On June 20, 2014, Crites was seen by Pavlovich for a follow-up. He noted that she continued to have pain and swelling. Crites indicated that the swelling was worse after she has been using her knee for a while and felt that she was unable to return to work at that time because of the continued problems. She was to remain off work until July 7, 2014 and then return to work with no restriction.

On June 23, 2014, Dr. Chuan Fang Jin evaluated Crites and diagnosed pre-existing degenerative arthritis of the right knee, history of acute flare-up of right knee, status-post chondroplasty and medial meniscal debridement.

Jin noted that from a medical perspective, Crites’ degenerative disease of the knee is not a result of the compensable injury but a pre-existing condition. She noted that it is common for symptoms of degenerative arthritis to manifest with or without obvious traumatic injury.  Based upon her report, the claims administrator denied Crites’ request to add the diagnosis of internal derangement and medial meniscal tear as compensable conditions in the claim.

On Aug. 6, 2014, Crites returned to see Pavlovich, complaining of continued pain and difficulty with kneeling, squatting and climbing. He recommended that Crites return to work on a trial basis with restrictions of no squatting, kneeling or climbing. She was seen again in October 2014 with similar complaints.

On Nov. 10, 2014, the Office of Judges reversed the claims administrator’s Jan. 23, 2014, decision and approved the diagnostic right knee arthroscopy. On Nov. 13, 2014, the Office of Judges reversed the claims administrator’s decision and held the claim compensable for a right medial meniscus tear, which was later affirmed by the Board of Review.

The Office of Judges issued a Nov. 26, 2014, order denying internal derangement of the right knee and approving medical meniscus tear.

 Crites sought treatment from Pavlovich throughout December 2014 and January 2015. He noted that Crites had pain with weight bearing and recurrent effusion. She continued to work but has had pain, catching and swelling in the knee.

On Jan. 29, 2015, the Office of Judges reversed the claims administrator’s July 30, 2014, decision denying the addition of the diagnosis of internal derangement and medial meniscus tear to the claim and added a medial meniscus tear in accord with the previous Nov. 26, 2014, Order.

The Board of Review affirmed the Office of Judges’ Order on April 27, 2015.

In 2015, Crites had exhausted therapy with cortisone injections and was advised to return to discuss surgical options. Upon her return, Pavlovich discussed surgical options including the option of repeating an arthroscopy. He recommended a unicompartmental knee replacement and Crites agreed with his request.

Pavlovich requested the surgery, as well as Percocet, Vicodin and Ultram as post-surgical treatment. He filled out an authorization for the same on Aug. 27, 2015.

On Sept. 1, 2015, Jin evaluated Crites and determined that she did not have any permanent impairment attributable to the injury in the claim. 

On Nov. 6, 2015, Jin issued a report that detailed her examination of Crites and noted that the medical evidence in the record clearly shows pre-existing advanced right knee arthrosis, which is the true indication for the requested surgery. She found that Crites will eventually need a total knee replacement but that such a request for treatment is not related to trauma or an injury.

Based on Jin’s report, the claims administrator denied the request from Pavlovich for right knee scope and the prescription medications, as well as unicompartment knee replacement surgery that occurred in November 2015.

On June 2, 2016, the Office of Judges found that the requested knee surgeries and medications following surgeries are not medically related and reasonably required for the treatment of a compensable condition. The Board of Review adopted the findings of the Office of Judges and affirmed its order

“After review, we agree with the findings of the Office of Judges as affirmed by the Board of Review,” the decision states. “The evidence of records supports the conclusion that the requested knee surgery and follow-up medications were not medically related and reasonably required to treat her compensable knee injury.”

The Supreme Court said they found the decision of the Board of Review is not in clear violation of any constitutional or statutory provision, nor is it clearly the result of erroneous conclusions of law, nor is it based upon a material misstatement or mischaracterization of the evidentiary record. 

W.Va. Supreme Court of Appeals case number: 16-1116

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