Pennsylvania: No Appeal of Utilization Review Determination Where Treating Provider Fails to Turn Over Records

A Pennsylvania appellate court held that where an employer files a request for utilization review of the medical treatment provided to claimant by a treating physician and that treating physician fails to provide the reviewing physician with the treating physician’s medical records, but a peer review report was nevertheless prepared indicating the treatment was unreasonable and unnecessary, the WCJ lacks jurisdiction to hear the appeal of the utilization review determination. The appellate court citing earlier precedent, noting that under 34 Pa. Code § 127.464, if the provider under review fails to mail records to the utilization review organization (URO) within 30 days of the date of request of the records, the URO must generally render a determination that the treatment under review was not reasonable or necessary.

Thomas A. Robinson, J.D., the Feature National Columnist for the LexisNexis Workers’ Compensation eNewsletter, is the co-author of Larson’s Workers’ Compensation Law (LexisNexis).

LexisNexis Online Subscribers: Citations below link to Lexis Advance.

See Allison v. Workers’ Comp. Appeal Bd. (Fisher Auto Parts, Inc.), 2018 Pa. Commw. LEXIS 40 (Jan. 12, 2018)

See generally Larson’s Workers’ Compensation Law, § 94.02.

Source: Larson’s Workers’ Compensation Law, the nation’s leading authority on workers’ compensation law