§ 127.471. Duties of reviewers—finality of decisions.
(a) Reviewers shall make a definite determination as to whether the treatment under review is reasonable or necessary. Reviewers may not render advisory opinions as to whether additional tests are needed. In determining whether the treatment under review is reasonable or necessary, reviewers may consider whether other courses of treatment exist. However, reviewers may not determine that the treatment under review is unreasonable or unnecessary solely on the basis that other courses of treatment exist.
(b) If the reviewer is unable to determine whether the treatment under review is reasonable or necessary, the reviewer shall resolve the issue in favor of the provider under review.
Notes of Decisions Basis of Utilization Reviewer’s Testimony
Utilization reviewer’s testimony that Claimant may have needed some other type of care did not violate the regulation disallowing determinations based solely on the fact that other courses of treatment existed; the reviewer also opined that the treatment rendered was unreasonable and unnecessary because it was of little value due to the time elapsed since the original injury. Howrie v. Workers’ Compensation Appeal Board (CMC Equip. Rental), 879 A.2d 820, 821 (Pa. Cmwlth. 2005).
Lack of Complete Medical History
The lack of a complete medical history does not, in itself, preclude the UR reviewer from assessing the reasonableness and necessity of treatment. As with any other evidence, the weight and credibility of the UR report are issues to be decided by the fact-finder. Solomon v. Workers’ Compensation Appeal Board (City of Philadelphia), 821 A.2d 215 (Pa. Cmwlth. 2003).
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