URO rejection upheld: further chiropractic treatment was not reasonable/necessary: claimant had 450 sessions over 3 years with no improvement and worsening of pain. Medical doctor competent to judge chiropractic treatment.

The claimant, a school police officer, injured his low back while trying to break up a fight. The employer accepted liability for the injury. Three-and-a-half years later, and following 450 chiropractic sessions, the employer filed a utilization review request to determine the reasonableness and necessity of ongoing chiropractic treatment. The utilization review found in favor of the claimant, and the employer appealed.

Before the judge, the employer offered medical evidence from orthopedic surgeons about the claimant's extensive degenerative disc disease, lumbar stenosis and radiculopathies, resulting in constant pain and numbness, despite ongoing, six-days-a-week chiropractic treatment that did not result in any overall improvement in the claimant's pain complaints. In granting the employer's petition, the judge found the medical reports of the orthopedic doctors credible and persuasive, citing to their qualifications and opportunity to physically examine the claimant.

The claimant challenged this decision, first arguing that the judge erred as the employer’s experts did not evaluate the chiropractic treatment under review. The court rejected this point, finding that the chiropractic treatment was repetitive and ongoing and that the experts reviewed numerous records indicating that such treatment did not result in increased function or decreased pain. Moreover, under Section 306(f.1)(6) of the Act, prospective utilization review of treatment is appropriate.

The claimant also contended that the orthopedic experts’ opinions should not be considered because they were not of the same discipline as the provider under review, as required by Section 306 (f.1)(6)(i) of the Act. In the court’s opinion, that section applies only to the initial utilization review by the UR organization and not a challenge to the UR decision. Instead, as long as the physician is competent to testify in the area of medicine under review, a judge may consider such evidence.

Case Law Alert - 3rd Qtr 2012