Consequences of Not Preparing a Physician Report Due to Failure to Produce Medical Records
In County of Allegheny v. Workers' Compensation Appeal Board (Geisler), 875 A.2d 1222, 1228 (Pa. Cmwlth. 2005), the claimant filed a utilization review petition with the Workers' Compensation Judge (WCJ) after the utilization review organization (URO) determined the provider's treatment was neither reasonable nor necessary, based on the provider's failure to supply the requested medical records.
The claimant appealed to the WCJ, who received additional evidence and determined the provider's treatment was reasonable and necessary.
The employer appealed the decision to this court, arguing that the WCJ lacked jurisdiction to review the merits of the URO determination because the determination did not include the reviewer's report.
The Court agreed with the employer, holding that "if a report by a peer physician is not prepared because the provider has failed to produce medical records to the reviewer, the WCJ lacks jurisdiction to determine the reasonableness and necessity of medical treatment." Geisler, A.2d at 1228.
The Court based our decision on Section 306(f.1)(6) of the Workers' Compensation Act (Act), 77 P.S. 531(6)(iv), which requires that the utilization review report be part of the record before the WCJ, and that the WCJ consider the report as evidence, even though it is not binding.
The Court explained that in situations where the URO renders a determination against the provider based on 34 Pa. Code 127.464(a), because the provider failed to supply the requested records, the URO may not assign the request to a reviewer under subsection (c), and therefore, the report the WCJ is required to review is never generated.
Without the required report the WCJ has nothing to review and lacks jurisdiction to address the necessity or reasonableness of the medical treatment.