A Utilization Review request that does not list all of a claimant’s treating providers does not render the request or the UR Determination invalid.

In this case, following the claimant’s April 2000 work injury, a C&R Agreement was approved by a Workers’ Compensation Judge and the medical portion of the claimant’s claim remained open. Approximately eight years later, a Utilization Review (UR) Requests were filed, seeking review of treatment the claimant was receiving relative to prescriptions for various medications, including OxyContin. It was determined that the prescriptions were not reasonable and necessary. The claimant filed petitions for review of the UR Determinations. 

The Workers’ Compensation Judge found that the medical evidence supported the recommended attempts to wean the claimant off the medications and reduce unnecessary medical visits. The claimant appealed to the Appeal Board and also asked the Board to remand the case to the Judge, based on new CDC Guidelines that had been issued after the appeal was filed. The Board affirmed the judge’s decision.

On appeal to the Commonwealth Court, the claimant argued the UR Requests were defective because they did not list all of his other treating providers. According to the claimant, for this reason, the reviewers were not provided with the opportunity to review all of his medical records, rendering the UR Determinations as void. The claimant maintained that the listing of other treatment providers on the UR Request form is mandatory and failure to do so should automatically render a UR Determination defective.

The court rejected this argument and dismissed the claimant’s appeal. According to the court, even if the reviewers did not conduct a review of medical records of other providers due to the failure to identify them on the UR Request form, it would not automatically mean the reviewers would be unable to render a determination of reasonableness or necessity. The court noted that the reviewers did, in fact, review medical records from the claimant’s other treating providers and further noted that the absence of other providers’ medical records, if any, goes to the weight of the evidence. 

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