§ 127.670. Hearings.
(a) The Director of the Bureau will assign appeals to decisions regarding a URO and PRO’s authority to review medical treatment to a hearing officer who will schedule a de novo hearing on the appeal from the initial decision. The URO/PRO will receive reasonable notice of the hearing date, time and place.
(b) The hearing will be conducted in a manner to provide the URO/PRO and the Bureau the opportunity to be heard. The hearing officer will not be bound by strict rules of evidence. All relevant evidence of reasonably probative value may be received into evidence. Reasonable examination and cross-examination of witnesses will be permitted.
(c) Testimony will be recorded and a full record kept of the proceeding. The Bureau and the URO/PRO will be provided the opportunity to submit briefs addressing issues raised.
(d) The hearing officer will issue a written adjudication within 90 days following the close of the record. The decision will include all relevant findings and conclusions, and state the rationale for the decision. The decision will be served upon the URO/PRO, the Bureau and counsel of record. The decision will include a notification to the URO/PRO and the Bureau of further appeal rights to the Commonwealth Court.
(e) The URO/PRO or the Bureau, aggrieved by a hearing officer’s adjudication, may file a further appeal to Commonwealth Court.
Notes of Decisions De Novo Hearing Required
Whether utilization review organization’s authorization to perform utilization reviews should be revoked was to be decided in a de novo hearing pursuant to regulations. Hearing officer’s deference to prior decision by Bureau of Workers’ Compensation to revoke URO’s authorization was clearly an appellate standard of review and inappropriate in this case. Chiro-Med v. Bureau of Workers’ Compensation, 879 A.2d 373, 381 (Pa. Cmwlth. 2005); appeal after remand 908 A.2d 980 (Pa. Cmwlth. 2006).
Utilization Review Mandatory
Workers’ Compensation Judge lacks subject matter jurisdiction to determine the reasonableness and necessity of medical treatment if the matter has not first gone to utilization review. County of Allegheny (John J. Kane Ctr.—Ross) v. Workers’ Compensation Appeal Board (Geisler), 875 A.2d 1222, 1228 (Pa. Cmwlth. 2005).
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment); 34 Pa. Code § 127.653 (relating to decision on application); and 34 Pa. Code § 127.669 (relating to revocation of authorizations).
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