Wednesday, October 29, 2003

Commonwealth Court Reviews Several Issues of Competency of Utilization Reviews

In M. Haynes v. WCAB (City of Chester) The Claimant took his doctor's testimony in support of physical therapy his doctor prescribed. In opposition, the Employer presented the Utilization Reviewer, a physical therapist. The WCJ also requested a Peer Review and the Bureau assigned a physical therapist. The WCJ credited the physical therapists. The Commonwealth Court rejected the Claimant's argument that the physical therapists' opinions were not competent. The Bureau procedure provides for appointing physical therapists to review physical therapy, and there could be no issue of causal connection to the work injury, an issue that would require competent medical testimony.

The Claimant in Haynes also did not prevail on his argument that the physical therapy he received provided palliative care, because the physical therapists reasoned it was not reasonable and necessary on the basis that it was repetitive, did not require skilled care, and incomplete.

In C. Havenstrite v. WCAB (Tobyhanna State Park), The Commonwealth Court en banc held the provider does not need to be consulted when his notes are characterized by the reviewer as "sketchy". The Court held this goes to the weight to be given to the reviewer's opinions.

The dissent noted the requirement of 34 Pa. Code Section 127.469 that states the reviewer shall initiate discussion with the provider when such a discussion will assist the reviewer in reaching a determination. The dissent would have combined this with the requirement that the issue be resolved in the favor of the provider if the reviewer is unable to determine whether the treatment is reasonable and necessary to hold the reviewer's opinions were incompetent.

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