Key takeaways:
- Utilization review can challenge whether treatment is reasonable and necessary.
- UR can review treatment before, during, or after care is provided.
- Insurers may withhold payment for treatment while UR is pending.
- Pennsylvania’s 90-day provider rule can limit early treatment choices.
- A UR determination can generally be challenged within 30 days.
A treating physician may believe that a first responder needs physical therapy, injections, medication, diagnostic testing, or another course of care, but that recommendation does not always end the workers’ compensation dispute. An employer or insurer can question whether treatment for an accepted work injury is reasonable or necessary through Pennsylvania’s utilization review process. That can create a difficult situation for a police officer, firefighter, EMT, or other responder who is still dealing with symptoms and trying to recover enough to return safely to demanding work.
Our workers’ comp attorney in Philly can help clarify an important distinction: utilization review does not decide whether the responder suffered a compensable injury in the first place. Understanding what gets reviewed, what happens to payment while the review is pending, and how an unfavorable determination can be challenged helps first responders react before a treatment dispute disrupts the recovery process.
What happens when work comp challenges a first responder’s medical treatment in Pennsylvania?
Pennsylvania uses utilization review, or UR, to determine whether medical treatment for a work injury is reasonable and necessary. The employee, employer, or insurer can request the review, although insurers commonly use the process when they question ongoing or proposed care.
An authorized Utilization Review Organization assigns the matter to a qualified reviewer. Pennsylvania regulations limit the reviewer to deciding whether the treatment under review is reasonable or necessary for the worker’s medical condition. The reviewer cannot reject care solely because another treatment option exists.
For a first responder, the dispute could involve treatment needed to manage an orthopedic injury, chronic pain, psychological condition, or another accepted work-related condition.
What types of treatment can undergo utilization review?
Pennsylvania permits prospective, concurrent, and retrospective utilization review. That means workers’ comp can question treatment before it occurs, while it is ongoing, or after the provider has already delivered it.
A request can concern treatment such as:
- Physical or occupational therapy
- Prescription medication
- Diagnostic testing
- Chiropractic treatment
- Injections
- Other ongoing or proposed medical care
The review focuses on treatment from the provider identified in the UR request. Pennsylvania’s 2026 guidance specifically notes that treatment from other providers will not undergo review unless they are separately listed as providers under review.
Can workers’ comp stop paying for treatment during utilization review?
In some circumstances, the insurer can suspend payment to the provider for the treatment under review while the UR process remains pending. That does not mean the utilization review itself medically orders the first responder to stop receiving care. It concerns whether workers’ compensation must pay for the disputed treatment.
The payment dispute should apply only to the treatment or portion of treatment being reviewed. Undisputed care remains subject to the ordinary payment requirements.
If the URO ultimately finds the treatment reasonable or necessary, the insurer must pay for it. A later petition asking a workers’ compensation judge to review that favorable determination does not continue the insurer’s right to withhold payment.
Does Pennsylvania’s 90-day provider rule affect treatment?
Yes, particularly early in a claim. If an employer properly establishes and posts a compliant panel of medical providers and gives the required notice, an injured employee generally must treat with a provider from that panel for the first 90 days after the initial visit.
The worker can choose among providers on the panel and may switch to another listed provider. After the 90-day period, the employee generally may choose another health care provider. If the employer’s panel or notice does not satisfy Pennsylvania requirements, the employee may have greater freedom to select a provider earlier.
This issue is separate from utilization review. Choosing an authorized provider does not prevent the insurer from later challenging whether particular treatment is reasonable or necessary.
Can a first responder challenge a utilization review determination?
Yes. A first responder who disagrees with a UR determination can seek review before a Pennsylvania workers’ compensation judge.
The petition must generally be filed within 30 days after receiving the URO determination. The employee, employer, insurer, or provider under review may file the petition.
Medical records and the reasoning behind the treatment can become important once the dispute reaches a judge. Missing that 30-day period can also limit the ability to contest the determination, making prompt review particularly important when the decision affects ongoing care.
Where can I find a workers’ comp attorney in Philly to help me challenge a denied treatment decision?
When workers’ comp starts questioning care your doctor believes is necessary, the dispute can quickly affect both recovery and your ability to return to the job safely. Liberty Bell helps first responders throughout Philadelphia understand why treatment was challenged and what options may be available next.
We can also advise on how an IRE may change disability status, what to do when light-duty work creates a new dispute, and what to review before agreeing to a workers’ comp settlement. If utilization review is delaying or threatening treatment tied to your work injury, contact our law office near Rittenhouse Square to have the decision, medical records, and next steps reviewed before important deadlines expire. Time is of the essence, so call us without delay!