Employer in PA Workers’ Comp Does Not Admit Injury By Requesting Utilization Review

When a workers’ compensation insurance carrier in PA does not believe the medical treatment rendered to an injured worker is reasonable and necessary, the appropriate course of action is for the insurance carrier to file for Utilization Review (UR). This was discussed in a previous blog entry. In this process, the PA Bureau of Workers’ Compensation will randomly assign a Utilization Review Organization (URO) to determine whether the treatment at issue is reasonable and necessary. The URO cannot address whether the treatment is related to the work injury.

This distinction became critical for the Commonwealth Court of Pennsylvania in Securitas Security Services v. Workers’ Compensation Appeal Board (Schuh). The injured worker fell off a chair and suffered a low back strain. Subsequently, the injured worker began to receive psychological treatment for depression. When the workers’ comp insurance carrier received bills for the psychological treatment, the carrier filed for UR.

A UR Determination was rendered by the URO, finding the treatment reasonable and necessary. The workers’ comp insurance carrier elected not to appeal this UR Determination.

The injured worker then filed a Petition to Review, seeking to add psychological injury to the accepted work injury. As evidence, the injured worker offered only the unappealed UR Determination. The Workers’ Compensation Judge (WCJ) granted the Review Petition, finding that the workers’ comp insurance carrier’s decision to institute the UR process, and the failure to appeal the UR Determination, effectively acknowledged the psychological injury was related to the work injury. The Workers’ Compensation Appeal Board (WCAB) affirmed.

On appeal, the Commonwealth Court of PA reversed. The sole issue to be decided by the URO was whether the treatment was reasonable and necessary. In fact, the law precludes a URO from even addressing the relatedness of a condition. As such, held the Court, a UR Determination, by itself, cannot support a Petition to Review to amend the description of injury.