Utilization Review

Brilliant & Neiman LLC protects injured workers throughout Southeastern and Central Pennsylvania, including Levittown, Bensalem, Jenkintown, Easton and Harrisburg. Since the attorneys with Brilliant & Neiman LLC are certified as specialists in the practice of PA workers’ compensation law, they have proven their qualifications to protect your rights under the Pennsylvania Workers’ Compensation Act.

One of the basic components of Pennsylvania workers’ compensation benefits is the ability to obtain medical treatment for the work injury. This benefit is not without limit, however. Only medical treatment which is “reasonable and necessary” is payable by the workers’ comp insurance carrier. This, of course, begs the question of what “reasonable and necessary” means and how it is determined.

The Pennsylvania appellate courts have made clear that treatment need not cure a condition to be “reasonable and necessary,” stating that relieving the symptoms of an injured worker can be enough. Most often, we see these challenges where treatment is “palliative” (relieving symptoms) rather than “curative.” Frequent examples include chiropractic treatment, therapeutic modalities, medications or injections.

When either party to a Pennsylvania workers’ compensation case wants an opinion on whether medical treatment is reasonable and necessary (and this is usually requested by the workers’ comp insurance carrier, rather than the injured worker), the procedure is to file a Request for Utilization Review (UR). When this step is taken by the insurance carrier, the obligation for the carrier to pay for the treatment under review is stopped, pending the outcome of the UR. The Pennsylvania Bureau of Workers’ Compensation then assigns a Utilization Review Organization (URO) randomly from a list.

Following submission of records by the doctor or practice under review to the URO, and frequently a personal statement from the injured worker, the URO issues a Utilization Review Determination. The burden to prove treatment is not “reasonable and necessary” remains with the workers’ comp insurance carrier throughout the UR process. If the treatment is found “reasonable and necessary,” the insurance carrier is again obligated to pay for the treatment under review. Note that treatment is often found “reasonable and necessary, in part,” meaning some aspect of the challenged treatment will no longer be covered.

The party against whom the URO finds has the right to appeal, by filing a Petition for Review of Utilization Review Determination. This Petition will be assigned to a Workers’ Compensation Judge (WCJ). The litigation of a Petition for Review of Utilization Review Determination is called a “de novo” proceeding. That translates to, roughly, “from the start.” In this situation, it means the parties are not limited to the evidence before the URO; instead, the parties can submit whatever evidence to the WCJ that they desire. Once a decision is made by the WCJ, as with any decision of a WCJ, appeal can then be made to the Workers’ Compensation Appeal Board (WCAB), and then the Commonwealth Court of Pennsylvania. Further appeal can be requested to the Supreme Court of Pennsylvania, though that appeal can be accepted or denied by the Court.

As you can imagine, this process is a bit complicated, and again shows the value of having a firm standing behind you, to protect all of your valuable workers’ compensation rights, including those to medical treatment.