• The Court Points Out That The Utilization Review Process Is Not The Proper Method To Determine Causation Of An Injury Or Condition.
  • March 2, 2018
  • The employer filed a Utilization Review Request to review compounded medication being given to the claimant, which was determined to be reasonable and necessary. The employer then filed a petition challenging the UR Determination, arguing the claimant was being treated for RSD/CRSP, which was not expressly accepted in the C&R Agreement. The claimant also filed a review petition requesting recognition of the RSD/CRPS as being related to the original work injury.

    The Workers’ Compensation Judge denied the employer’s UR Petition and granted the claimant’s review petition, holding the RSD/CRPS was within the scope of the C&R Agreement. The employer appealed to the Workers’ Compensation Appeal Board, which reversed the judge’s decision and determined that the C&R Agreement precluded the claimant from expanding the description of his injury.

    The Commonwealth Court reversed the Board. In doing so, it noted that the employer did not contend that the challenged treatment was not reasonable and necessary for the claimant’s pain but, rather, argued it should not be liable for the treatment because the C&R Agreement only accepted responsibility for “fractured right and left feet.” The court pointed out that the utilization review process was not the proper method to determine causation of an injury or condition. Although the court agreed that the Appeal Board correctly concluded the claimant could not expand the description of the injury acknowledged in the C&R Agreement, they also found that the Board was wrong to conclude that the medical treatment at issue was beyond the scope of the C&R Agreement.