- On Petition Appealing a Utilization Review Determination, The Board Reversed the UR Decision and Held That the Claimant’s Treatment was Not Necessary and Reasonable.
- July 3, 2018
This case involved the employer’s appeal from a Utilization Review decision, which had determined that the treatment for pain management—including prescription medications, office visits, chiropractic and acupuncture—was Guideline compliant.The Board noted that, since the employer was the party challenging the Utilization Review Determination, it had the burden of proof. The issue in the Utilization Review Determination was whether the challenged treatment was within the applicable Health Care Practice Guidelines. However, the issue before the Board was whether the challenged treatment was necessary and reasonable for the accepted work injury.The issue, as phrased by the Board, was whether the treatment with the claimant’s expert—specifically his prescription medications, office visits, chiropractic care and acupuncture from July 2017, and ongoing—was necessary and reasonable treatment for the work injury. The Board concluded that the treatment in question was not necessary and reasonable. In ruling as it did, the Board was also persuaded by the significant gaps in the claimant’s treatment as being indicative of her lack of need for treatment.The Board also accepted as credible the testimony of the employer’s medical expert, concluding that this doctor’s testimony that the claimant’s symptoms were magnified—her subjective complaints were not corroborated by objective findings—was clearly supported by the evidence. The Board concluded that the employer had met its burden of proof. Its petition was granted, and the Utilization Review decision was reversed.