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What Is a Workers’ Compensation Utilization Review?

Pennsylvania’s workers’ compensation law allows an insurance company, an employer or an injured worker to request a utilization review (UR), if they suspect that a course of medical treatment is not reasonable or necessary. The process begins when an interested party files a UR request. The case is assigned to a utilization review organization (URO), which requests medical records from the provider who has recommended the treatment. The URO will issue a decision as follows:

  • Yes — The treatment is reasonable and necessary for the dates planned.
  • No — The treatment is not reasonable and necessary for the dates planned.
  • Part yes/part no — Some of the treatment is reasonable and necessary and some is not, or the treatment is reasonable and necessary but not for the entire period of time contemplated.

If you are an injured worker, you have the most to lose or gain in the URO’s determination if they determine your treatment is not reasonable or necessary; it means workers’ compensation will not pay for it. That does not mean you will be stuck with the bills if you have been receiving treatment, but you will not be able to continue with treatment that may have been helping your condition unless you pay for it yourself.

You have the right to make a statement to the URO about your opinion of the treatment in question. You should be told of this right in a “Notice to Injured Worker” mailed to you at home. If the URO’s decision is contrary to your interest, you have the right to petition the URO.

To make your statement to the URO as effective as possible, you may want to consult an experienced workers’ compensation attorney. An attorney can also help you appeal the URO’s decision, if it goes against your interests.

Rudberg Law Offices, LLC represents employees of all backgrounds in workers’ compensation disputes. If you have received notice of a utilization review, schedule a free consultation by calling 412-488-6000 or contacting our Pittsburgh office online.

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