§ 127.406. Scope of review of UROs.
(a) UROs shall decide only the reasonableness or necessity of the treatment under review.
(b) UROs may not decide any of the following issues:
(1) The causal relationship between the treatment under review and the employe’s work-related injury.
(2) Whether the employe is still disabled.
(3) Whether ‘‘maximum medical improvement’’ has been obtained.
(4) Whether the provider performed the treatment under review as a result of an unlawful self-referral.
(5) The reasonableness of the fees charged by the provider.
(6) The appropriateness of the diagnostic or procedural codes used by the provider for billing purposes.
(7) Other issues which do not directly relate to the reasonableness or necessity of the treatment under review.
Notes of Decisions Causal Relationship
The Workers’ Compensation Appeal Board did not abuse its discretion by denying the claimant’s request to remand the matter to the Workers’ Compensation Judge to receive the ‘‘after discovered’’ utilization review organization (URO) determination, because the scope of review of a URO is strictly limited to reviewing the reasonableness and necessity of medical treatment, the URO’s decision that the physical therapy provided to the claimant was reasonable and necessary does not establish that the treatment was causally related to the claimant’s work-related injury or that the claimant remains disabled by his work-related injury. Corcoran v. Workers’ Compensation Appeal Board, 725 A.2d 868 (Pa. Cmwlth. 1999).
General Comment
Clearly, this regulation recognizes a distinction between an issue concerning causation as opposed to reasonableness and necessity of treatment. An action concerning causation cannot be raised before a URO; therefore, it must be raised in a petition that is intended to be heard directly by a WCJ. Likewise, an action concerning the reasonableness and necessity of treatment is to be raised in a request for UR that will be submitted to a URO. Bloom v. Workmen’s Compensation Appeal Board, 677 A.2d 1314 (Pa. Cmwlth. 1996); appeal denied 684 A.2d 558 (Pa. 1996).
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