§ 127.405. UR of medical treatment in medical only cases.
(a) In medical only cases, when an insurer is paying for an injured worker’s medical treatment but has not either filed documents with the Bureau admitting liability for a work-related injury nor has there been a determination to the effect, the insurer may still seek review of the reasonableness or necessity of the treatment by filing a request for UR.
(b) If the insurer files a request for UR in a medical only case, the insurer is responsible for paying for the costs of the UR.
(c) If the insurer files a request for UR in a medical only case, then the insurer shall be liable to pay for treatment found to be reasonable or necessary by an uncontested UR determination.
Source The provisions of this § 127.405 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203490).
Notes of Decisions UR Decision Not Moot
Decision arising from employer’s utilization review request which was filed prior to claimant’s claim petition was not rendered moot because a WCJ never has original jurisdiction over issues concerning reasonableness and necessity; the purpose of the regulation is to encourage payment of medical bills in cases that are, at least initially, medical only. Krouse v. W.C.A.B. (Barrier Enters. Inc.), 837 A.2d 671, 674—675 (Pa. Cmwlth. 2003).
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