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Reasonableness and Necessity of Medical Treatment During Litigation of Claim Petition

Case Name:Chick-Fil-A v. WCAB (Mallick), February 25, 2002
Synopsis:FACTS:Claimant filed Claim Petition alleging work related low back injury.  The Workers' Compensation Judge granted the Claim Petition granting payment of medical expenses characterized by the Workers' Compensation Judge as reasonable and necessary.  However, neither party had requested Utilization Review prior to the issuance of the Judge's Decision on the Claim Petition.

DECISION: A Workers' Compensation Judge is without jurisdiction to decide the reasonableness and necessity of medical expenses where liability for a work injury has not been established.

REASONING:Liability of injury must be established before the 30 day period for filing of a Utilization Review Request (34 Pa. Code § 127.404b) commences.

Practice Points:

In context to litigation on Claim Petition, diary case for review of Workers' Compensation Judge's decision granting Claim Petition in order to determine if Utilization Review procedures should be invoked.

Under the Utilization Review procedures insurer has 30 days after receipt of medical bills to challenge treatment.  Once liability is determined via Workers' Compensation Judge's Decision on a Claim Petition, insurer has 30 days to file Utilization Review for investigation or review of medical treatment.