§ 127.470. Duties of reviewers—issues reviewed.
(a) Reviewers shall decide only the issue of whether the treatment under review is reasonable or necessary for the medical condition of the employe.
(b) Reviewers shall assume the existence of a causal relationship between the treatment under review and the employe’s work-related injury. Reviewers may not consider or decide issues such as whether the employe is still disabled, whether maximum medical improvement has been obtained, quality of care or the reasonableness of fees.
Notes of Decisions Assumption by Reviewer
The reviewing physicians properly assumed a causal relationship between the treatment and the back injury that was the only recognized injury. There was no requirement to make an assumption with respect to the non-back injuries; therefore, the conclusions that the treatment for the non-back injuries was neither reasonable nor necessary were properly accepted as competent and credible, satisfying the employer’s burden. Reinhardt v. Workers’ Compensation Appeal Board, (Mt. Carmel Nursing Center) 789 A.2d 871 (Pa. Cmwlth. 2002).
Causal Relationship
The Workers’ Compensation Appeal Board did not abuse its discretion by denying the claimant’s request to remand the matter to the workers’ compensation judge to receive the ‘‘after discovered’’ utilization review organization (URO) determination, because the scope of review of a URO is strictly limited to reviewing the reasonableness and necessity of medical treatment, the URO’s decision that the physical therapy provided to the claimant was reasonable and necessary does not establish that the treatment was causally related to the claimant’s work-related injury or that the claimant remains disabled by his work-related injury. Corcoran v. Workers’ Compensation Appeal Board, (Capital City Times Leader) 725 A.2d 868 (Pa. Cmwlth. 1999).
Quality of Care
Physician who performed utilization review did not violate statute prohibiting reviewers form considering or deciding ‘‘quality of care’’ issues by finding that medication prescribed by provider for workers’ compensation claimant was unreasonable and unnecessary when he stated preference for safer medications; it was entirely appropriate for reviewer, in determining the reasonableness and necessity of a prescribed medication, to consider risk to the patient. Sweigart v. Workers’ Compensation Appeal Board (Burnham Corp.), 920 A.2d 962, 965 (Pa. Cmwlth. 2007)
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