A prior utilization review Determination, finding treatment the claimant received from the same chiropractor to be reasonable and necessary, does not estop the employer from requesting utilization review of that same treatment in the future.

In this case, the employer filed a utilization review (UR) request concerning the reasonableness and necessity of chiropractic treatment being provided to the claimant beginning December 31, 2007. Previously, a decision had been issued by a workers' compensation judge in November of 2003, ordering the employer to pay for the claimant's treatment with the chiropractor on and after June 11, 2002. In 2007, the employer sought UR of the same chiropractor. A determination was issued finding that the ongoing treatment was unreasonable and unnecessary. The claimant filed a petition challenging the determination, which was dismissed by the workers' compensation judge. The Workers' Compensation Appeal Board affirmed the decision of the workers' compensation judge, as did the Commonwealth Court. The court rejected the claimant's argument that the 2003 UR decision, ordering the employer to pay for chiropractic treatment on and after June 11, 2002, precluded the employer from re-litigating the issue of whether the claimant was improving from the treatment since that argument was previously rejected as not credible. The court pointed out that in the first UR petition, a request was made for review of the reasonableness and necessity of medical treatment after June 11, 2002, and the second petition sought review of the reasonableness and necessity of medical treatment after December 31, 2007, a difference of five years and six months. Moreover, the court found that there was credible evidence in the record showing that there was a change in the claimant's condition since the prior 2003 UR decision.

Case Law Alert - 4th Qtr 2011