Serial Killer: Delaware IAB Addresses the Issue of Treatment Post-UR Non-Cert…and How Long Does a UR Non-Cert “Stick”?

I discovered for the first time since the inception of The Detour & Frolic, that there are times I just don't feel blog-motivated...today being one of them.  I want to share, I want to banter, but my shoulder hurts and I am cranky form having the spent a 3-day weekend doing something that is not even close to recreation.  Ugghhh! But then along comes Danielle Yearick and takes up the lead on heralding a more than blog-worthy development.  As I always say, you gotta love those Motion days at the IAB!

So here it is......Kim Butcher v. Wilmington Trust, IAB#1339380 (9/4/12)(ORDER)...and it is a keeper.

Here is what Danielle had to say:

"Carriers can rely on an un-appealed UR to deny future treatment already addressed by the UR and carriers do not have to submit a second UR simply because it's a new provider or a gap in time since the prior treatment-- claimant bears the burden of demonstrating that the renewed treatment was due to a change or worsening of a claimant's condition since the prior treatment had ceased/was deemed noncompliant. If claimant meets that burden, the prior UR does not per se preclude the compensability of the treatment, but the carrier has NOT waived its right to then UR that treatment and can then do so.

This prevents carriers from having to UR treatment already deemed noncompliant on multiple occasions. It places the burden on claimant to demonstrate a change in condition to justify the resumed treatment that was previously deemed noncompliant.  And, it extends the UR filing deadline on that treatment if claimant meets that burden.

In my case, there was a 7 month period between the end of the treatment that was deemed noncompliant by UR and the start of treatment with a different provider (same specialty); new provider's bills were denied based on the prior UR addressing those treatment modalities.....More than 2 years of "new" treatment had accrued before this DACD petition was filed for the bills. The Hearing is next week to address claimant's burden to establish  a change in condition.  Good news is that even if claimant shows a change in condition to justify the treatment, the carrier can still retrospectively UR all those bills.

Lastly, where claimant alleges that the renewed treatment is different from or not addressed by the prior UR and should therefore not have been denied based on the prior UR, claimant must identify with specificity the treatment modalities and expenses that she claims were not addressed or considered in the prior UR.

Of course, this basically all becomes moot if the 45 day UR appeal deadline is deemed unenforceable.

Strangely, though, claimant has still never filed an appeal of the original UR."

I thank you, Danielle for the complete analysis of an issue heretofore without consideration.  One of these days when I author that treatise on UR, or that multi-volume e-cyclopedia of Delaware comp law....this will no doubt be included.

Irreverently yours,
Cassandra Roberts

Delaware Detour & Frolic   Visit Delaware Detour & Frolic, a law blog by Cassandra Roberts

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