Commonwealth Court Upholds Decision Granting a Petition to Review Utilization Review Determination
The Commonwealth Court, in Loc, Inc. v. WCAB (Graham), ruled in favor of a claimant, upholding a decision granting a Petition to Review Utilization Review Determinations. The employer had filed Utilization Review Request to challenge the reasonableness and necessity of medications prescribed by the claimant's treating physician. The Utilization Review Organization (URO) requested medical records from the claimant's doctor. The doctor provided records, but the URO found the doctor's treatment not medically reasonable or necessary because, while the dovtor had provided records, "there is not documentation of significant efficacy of the medication prescribed." The claimant filed a Petition to Review the Utilization Review Determination, and the workers' compensation judge found the prescriptions were, in fact, reasonable and necessary. The employer sought to have the judge's decision reversed, citing the Court's prior decision in Geisler. However, the Court distinguished this case from Geisler by noting that in Geisler, the provider failed to forward any medical records to the URO, and no UR Determination was issued, and the provider and claimant were barred from appealing the matter any further. In the instant case, the doctor did forward medical records -- just not records which the URO anticipated or sought.
