Commonwealth Court clarifies that a utilization review challenge to physical therapy treatment need not name each individual therapist who provides treatment.
Since the decisions in Schenck v. WCAB (Ford Electronics), 937 A.2d 1156 (Pa. Cmwlth. 2007), and Bucks County Community College v. WCAB (Nemes), 918 A.2d 150 (Pa. Cmwlth. 2007), employers have been faced with the challenge that a utilization review request must be provider-specific and does not apply to treatment rendered by providers other than the one named. In this case, the Commonwealth Court has identified an exception to that principle in the case of physical therapy treatment. Recognizing that physical therapy treatment is prescribed by a physician and may be carried out by different therapists, the court found that it is not reasonable to require an employer to name each individual therapist as a "provider." Likewise, separate UR challenges to the same course of therapy could lead to inconsistent results as to its reasonableness and necessity. In MTV Transportation, the court held that when making a UR request for physical therapy prescribed by a doctor and administered in that doctor's facility, the employer must name the doctor prescribing the physical therapy and the facility where the claimant receives that therapy. The court noted, however, that there might be cases where the challenge is to the physical therapist's treatment itself rather than the doctor's prescription of it. Likewise, the court's rationale should apply to physical therapy not provided at the doctor's facility. This holding is significant as it allows a single UR challenge to physical therapy treatment rather than multiple reviews of treatment from different therapists.
Case Law Alert - 3rd Qtr 2010