Claimant cannot rely on prior Utilization Review Determinations, which established prescription medications were reasonable and necessary, in order to show in later penalty petition that these medications were causally related to injury and payable.

During the claimant’s receipt of workers’ compensation benefits, two Utilization Review (UR) Determinations were issued, finding all of the medications being prescribed by a certain physician were reasonable and necessary. The claimant later filed a penalty petition, alleging the employer violated the Act by not paying for his medications, many of which were previously found to be reasonable and necessary in the UR Determinations.

The Workers’ Compensation Judge denied the petition, finding the medications were not paid based on either lack of causation issues or a billing code issue. The judge accepted the opinions of the employer’s medical experts that medications not paid for were unrelated to the work injury. The Appeal Board affirmed.

At the Commonwealth Court level, the claimant argued the non appealed UR Determinations found that the medications in question were reasonable and necessary. In other words, the claimant relied on the UR Determinations to show that the medications were related to the work injury. The court dismissed the claimant’s appeal, noting that UR Determinations do not decide causation, only the reasonableness and necessity of treatment. The court also rejected the claimant’s argument that the employer’s denial of payment on the basis of billing code issues was “improper.” The court said maybe so, but no evidence was presented by the claimant on the issue (denied bills were resubmitted for payment with proper coding) and that it was not their job to develop the claimant’s legal argument.

_{What’s Hot in Workers’ Comp, Vol. 26, No. 9, September 2022 is prepared by Marshall Dennehey to provide information on recent legal developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. We would be pleased to provide such legal assistance as you require on these and other subjects when called upon. ATTORNEY ADVERTISING pursuant to New York RPC 7.1 Copyright © 2022 Marshall Dennehey, all rights reserved. No part of this publication may be reprinted without the express written permission of our firm. For reprints or inquiries, or if you wish to be removed from this mailing list, contact tamontemuro@mdwcg.com.}