The Commonwealth Court rejected the employer’s proposed twist on the Bucks County decision holding that a utilization review determination that treatment is not reasonable and necessary cannot be applied to other providers of the same treatment. Here, the employer argued that a prospective URO is fundamentally different from a retrospective URO such that it would be unduly burdensome for the UR Determination not to apply to similar treatment by a similarly qualified provider. The Court unabashedly rejected the argument and reiterated that all UR Determinations are provider specific. 

What It Means to You

It is easier than ever for claimants to avoid the ramifications of a UR determination limiting their medical treatment. Employers need to vigilantly review medical bills in order to maximize the cost containment provisions of the Act. Unfortunately, constant UROs are time consuming and expensive. Contact a C&W Workers’ Compensation attorney to determine the best strategy for mitigating your medical benefits exposure.