On February 12, 2007, the Pennsylvania Commonwealth Court issued a decision in a case involving utilization review (UR) of an injured workers medical treatment. In Bucks County v. WCAB (Nemes), 918 A. 2d 150, the employer had filed a UR request seeking a review of the reasonableness and necessity of all medical treatment provided to Claimant by Daniel Files, D.O. with the following notation: “and all other providers under the same license & specialty.” The URO report noted that records from Dr. Files (the provider under review) included an October 1, 2001 narrative report transcribed on Bucks Family Medicine stationery and handwritten notes from Dr. Files/Dr. Thomas Mercora dated from July 16, 2004 through October 22, 2004. The URO reviewer, in finding that some of the treatment was not reasonable nor necessary, focused his decision on the treatment offered by Dr. Mercora.

The Commonwealth Court held that, because employer identified Dr. Files as the provider under review and the workers compensation judge (WCJ) found that there was no evidence presented as to the treatment rendered by Dr Files, nor any opinion by the utilization reviewer as to reasonableness or necessity of Dr. Files’ treatment, the utilization reviewer’s report was invalid.

The Court noted that the provisions of the Workers’ Compensation act regarding utilization review applied to individual providers. Therefore, the UR determination was void since the UR reviewer focused on the wrong doctor in rendering the determination.

Thomas P. Cummings, Esq.
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