Warmest holiday greetings to one and all. In August, 2009, I reported on the decision in C. Maude Donovan v. Kent Construction in which the IAB held that the
UR decision should be barred from consideration by the Board in an appellate hearing. The Board relied on the proposition that "de novo hearing", which is the legal standard established for the right of appeal by statute, meant fresh consideration of the medical treatment issue without any regard for the Utilization Review findings below. [See my posting of 8/17/09-- "A Rose by Any Other Name: De Novo Means De Novo"].
I am delighted to report that there is a recent decision on this same issue of admissibility of the UR decision in an IAB UR appellate hearing, Daniel Meier v. Tunnell Companies, IAB Hrg. # 1326876 (11/24/09 (Order). Great stuff that turns the C. Maude Donovan case on its ear in terms of a much more thorough and well-reasoned analysis which concludes that the decision is relevant to the appeal, and trust me, you will like this one irrespective of which side of the legal fence you pitch your tent.
The medical treatment issue on de novo review by the IAB is not solely whether or not the treatment is within the Practice Guidelines. The hearing officer who authored this ruling acknowledged that what UR has to say regarding compliance with the Practice Guidelines is relevant and we know from other recent postings that the IAB is ready to pounce if it perceives that the
UR analysis has, for example, misapplied those Guidelines or based its analysis on review of incomplete medical records. This case, however, brings into focus the potential under our new statute that medical treatment is within the Guidelines and still unreasonable or outside the Guidelines and nonetheless (in its perception) reasonable and necessary and as such, compensable. Remember, that "reasonable and necessary" standard of medical treatment will still trump the Practice Guidelines if an appeal is taken from Utilization Review….and so it goes.
A thoughtful deliberation from neophyte Hearing Officer Angela Fowler. Check it out!
Visit Delaware Detour & Frolic, a law blog by Cassandra Roberts