Utilization Review in PA Workers' Comp: How to Challenge a Treatment Denial

When the Insurer Attacks Your Treatment Instead of Your Claim

Sometimes an insurer accepts that your injury is work-related but then targets the care itself, arguing your treatment is "not reasonable or necessary." The formal process it uses is called Utilization Review (UR). For brain-injury patients who depend on ongoing therapy, medication, and specialist care, a UR can threaten the very treatment your recovery is built on.

How Utilization Review Works

• Either side can file a UR request with the Bureau of Workers' Compensation—but it's usually the insurer, challenging a specific provider's treatment.
• The case is assigned to a neutral Utilization Review Organization (URO), which uses an independent, same-specialty reviewer.
• The reviewer examines your medical records (and any statement you provide) and decides whether the treatment under review is reasonable and necessary.
• While a UR is pending on treatment already being provided, the insurer generally may withhold payment for that specific treatment until the determination.

What a UR Determination Means

The URO issues a written Utilization Review Determination:

• If treatment is found reasonable and necessary, the insurer must pay.
• If found not reasonable or necessary, the insurer doesn't have to pay for that treatment.

Crucially, a UR decides only whether specific treatment is payable—it does not end your claim or say your injury isn't real.

How to Challenge a Denial

A bad UR determination is not the end of the road. You can file a Petition for Review of the UR Determination, which sends the dispute to a Workers' Compensation Judge. Before the judge, you can present:

• Testimony and records from your treating physician
• Neuropsychological and imaging evidence documenting the brain injury
• Evidence of functional improvement the treatment provides

The judge is not bound by the URO and makes an independent decision.

Why Brain-Injury Care Gets Targeted

Cognitive therapy, vision therapy, counseling, and long-term medication management are exactly the kinds of care insurers like to label "maintenance" or "excessive." Detailed documentation of why the care is working—and what happens without it—is the key to defeating a UR.

How We Help

Certified Workers' Compensation Specialist Michael Cardamone handles UR challenges directly, building the medical record needed to keep your treatment funded. Where a third party is also responsible, we coordinate that claim with heavyweight personal injury colleagues.

Treatment Denied? Fight It—Free Consultation

If your comp insurer cut off treatment through Utilization Review, you have the right to challenge it. Call (833) 898-4587—free, confidential, 24/7, no fee unless we win.