The Commonwealth Court finding that combined dosages of OxyContin and Oxycodone were excessive and not reasonable and necessary was supported by substantial competent evidence as it was based on competent and credible opinion of reviewing provider.

Following the claimant’s work injury, the employer filed a Request for Utilization Review (UR) regarding pain management treatment the claimant was receiving. Specifically, a review was sought for the reasonableness and necessity of prescriptions for OxyContin, 60 mg twice per day, and Oxycodone, 10 mg four times per day. The Utilization Review Organization (URO) reviewer noted that the claimant’s morphine equivalent dose was at a red flag level, per CDC Guidelines. The reviewing provider found that, because the prescriptions exceeded the Guidelines, they were not justified during the period under review. Nevertheless, the reviewing provider also found that the medications were reasonable and medically necessary at a continuing and tapering dosage.

The claimant filed a petition challenging the UR Determination, which the Workers’ Compensation Judge dismissed, finding the opinion of the reviewing provider to be credible. The judge also accepted the reviewing provider’s tapering recommendations. The claimant appealed to the Appeal Board (Board), and they affirmed.

The claimant then appealed to the Commonwealth Court, arguing that the judge’s decision was not supported by substantial evidence. Essentially, the claimant contended that the reviewing provider’s opinion was not competent based on the provider’s failure to consider the opinions of the claimant’s treating physicians. The Commonwealth Court rejected this argument and dismissed his appeal. The court pointed out that, even had they considered the claimant’s assertion that the opinion of the reviewing provider was incompetent because he did not speak to one of the claimant’s treating physicians, the claimant would not be entitled to relief. The court based its decisions on prior case law holdings, that a UR reviewer’s failure to speak with a claimant’s health care provider or review a claimant’s entire medical file does not preclude the reviewing provider from making a determination of the reasonableness or necessity of a particular treatment, nor does it preclude a judge from crediting a UR report.

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