Residency at a long-term care acute facility as opposed to a skilled nursing facility.
Whether a claimant’s presence at a long-term acute facility was reasonable or necessary was an issue directly related to the reasonableness or necessity of the treatment under review and, therefore, Utilization Review requests filed with the Bureau should have been assigned to a Utilization Review Organization.
James Burgess v. WCAB (Patterson-UTI Drilling Company LLC); 778 C.D. 2019; filed May 1, 2020; Judge Covey
The claimant sustained a work injury on December 28, 2012. The employer accepted the claim under a Notice of Temporary Compensation Payable that later converted to a Notice of Compensation Payable. Two years after the injury, the claimant was residing at a long-term acute care (LTAC) facility.
The employer filed a Utilization Review request regarding the reasonableness and necessity of the claimant’s continued presence at the LTAC facility. The Bureau returned the request because the treatment to be reviewed was not a health care service. The employer filed a second UR request, and it was again returned by the Bureau without assigning it to a Utilization Review Organization (URO). The employer then filed a third UR request, this time asking for a review of the reasonableness and necessity of the treatment the claimant was receiving from providers at the LTAC facility. A URO determined that the medical treatment was reasonable and necessary. The employer then filed a Utilization Review petition.
Before the workers’ compensation judge, the employer clarified that they were asking the judge to address the reasonableness and necessity of the claimant’s continued residency at the LTAC facility, as opposed to a skilled nursing facility. The judge concluded that the employer sustained its burden of showing that the stay was not reasonable and necessary, and that the claimant should be moved to a skilled nursing facility. The claimant appealed to the Appeal Board, which affirmed the judge’s decision.
On appeal to the Commonwealth Court, the claimant argued that the judge lacked jurisdiction to determine whether the claimant’s care should be transferred from an LTAC facility to a skilled nursing facility because the determination was beyond the scope of the permissible Utilization Review consideration. According to the claimant, § 127.406 (b)(7) of the Department Regulations prohibited the URO from considering whether the claimant’s receipt of care at the LTAC facility was reasonable and necessary because the claimant’s presence there did “not directly relate to the reasonableness or necessity of treatment under review.”
The court disagreed and found that the critical question was whether the claimant’s presence at the LTAC facility was reasonable or necessary for the reviewed provider’s treatment to be effective; an issue directly related to the reasonableness or necessity of the treatment under review.
Because the URO never conducted a Utilization Review with respect to the claimant’s LTAC facility stay, the court concluded the workers’ compensation judge did not have jurisdiction to render a decision on that issue. The court held that the employer’s original Utilization Review requests regarding the reasonableness and necessity of the claimant’s stay at the LTAC facility were not prohibited by the Department’s regulations and should have been referred for a Utilization Review determination. The court also held that the judge should have remanded the issue to the Bureau, with a direction that the employer’s requests be assigned to a URO.
The court, therefore, vacated and remanded with instructions to the judge to direct the Bureau to assign the employer’s original Utilization Review request to a URO for a Utilization Review determination.
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