Finding out your treatment is being reviewed, usually through a billing problem rather than a phone call, is unsettling when that treatment is what keeps you functioning. Zavodnick & Lasky Personal Injury Lawyers represent injured workers in Philadelphia through those disputes.
Most injured workers here learn the phrase “utilization review” from that billing problem. The physical therapy visits keep happening, the bills stop getting paid, and the front desk mentions that the case is “in review.”
That review is a formal proceeding under the Workers’ Compensation Act, and it decides whether your employer’s insurer keeps paying for the treatment you are on. Reach the office at (215) 875-7030.
What is a utilization review in a Pennsylvania workers’ comp claim?
A utilization review is an independent look at whether the medical treatment you are receiving for an accepted work injury is reasonable and necessary. It does not ask whether you were hurt at work, and it does not reopen liability. Your claim stays accepted either way.
Section 306(f.1)(6) of the Pennsylvania Workers’ Compensation Act governs the process. The request goes to the Bureau of Workers’ Compensation, which assigns the file to an authorized Utilization Review Organization, and the Bureau describes the process and its legal basis on its health care services review page. A reviewer then reads your treating provider’s records and issues a determination on the treatment under review, provider by provider and period by period.
Who asked for it, and what the insurer is after
In practice the insurer files it, usually after treatment has run past the point its adjuster budgeted for. Chiropractic care, injections, long-running physical therapy, and prescription pain management draw these more than anything else. Workers and providers can file one too, though that is rarer.
The target matters. A utilization review is aimed at a named provider and a named window of treatment, so a determination against your physiatrist does not touch your orthopedist, and a determination covering treatment from March forward says nothing about January. Insurers sometimes file several in sequence, one provider at a time, which is worth recognizing early because the pattern says something about where the claim is heading.
Call (215) 875-7030 if a notice naming one of your doctors has arrived.
What happens to your treatment while the review is pending?
You can keep going to your appointments. What changes is the bill: the insurer’s obligation to pay for the treatment under review is on hold until the determination comes out, which is why the office staff notices the problem before you do.
| Stage | What it means for you |
| Request filed and assigned to a review organization | Treatment continues, payment for the reviewed treatment pauses |
| Your provider sends records | The single most important step, and the one with a hard deadline |
| Reviewer issues the determination | Treatment is found reasonable and necessary, or it is not, for that provider and period |
| Either side files a petition for review | A workers’ compensation judge hears the question again, with live testimony |
A missed records deadline on the provider’s end is the quiet way these get lost. When no records arrive, the reviewer has nothing to find reasonable, and the determination reflects that rather than the merits of your care.
What your treating doctor’s file has to show
Reviewers are looking for a record that connects the treatment to the work injury and shows it is doing something. Notes that repeat the same three lines for six months read as maintenance, and maintenance is where determinations turn against workers.
The file does better when it documents function rather than pain scores alone: what you could not do in March that you can do now, how many degrees of motion came back, what the therapist measured. It helps when the provider states plainly why the treatment is still needed and what happens without it.
This is where a lawyer earns the fee before any hearing happens, by telling your provider what the reviewer needs to see and making sure the records leave the office on time.
If the determination goes against you
You are not stuck with it. Either party can file a petition for review, and the Bureau’s own guidance is that the petition is heard and decided by a workers’ compensation judge. The deadline is short, counted from the determination, so this is a week-of decision rather than a think-about-it decision.
What happens in front of the judge is a fresh look, not an appeal on the paper record. You can testify about what the treatment does for you. Your doctor can testify or give a deposition. The judge decides the question again rather than reviewing the reviewer’s reasoning, which is a meaningful advantage for a worker whose file looked thin but whose treatment is genuinely helping.
Common questions about utilization review in Pennsylvania
Can my employer’s insurance company cut off my physical therapy?
Not on its own. The insurer has to file a utilization review and get a determination that the treatment is not reasonable and necessary, and even then the determination reaches only the provider and the time period named in the request. You can challenge it in front of a judge.
Do I have to stop treatment during a utilization review?
No. You can keep your appointments, and stopping treatment while the review is pending tends to hurt, since gaps in care show up later as evidence the treatment was not needed. Talk to your provider about how it wants to handle billing in the meantime.
Who picks the doctor that reviews my treatment?
Neither you nor the insurer does. The Bureau assigns the file to an authorized review organization, which uses a reviewer licensed in the same profession as your provider, so a chiropractor’s treatment is reviewed by a chiropractor.
How long do I have to appeal a utilization review determination?
The window to file a petition for review is short and runs from the determination itself. Bring it to a lawyer the same week it arrives, because the filing is what preserves your right to be heard.
Get the determination looked at this week
Utilization review is one half of how an accepted claim gets narrowed without a denial. The other half is the impairment rating evaluation, which goes after the wage-loss side. Workers who see one often see the other within the year.
Zavodnick & Lasky Personal Injury Lawyers take these cases on a contingency basis, so the fee comes out of what is recovered and a judge approves it. If a review has been filed against your treatment, a determination has already come back, or your claim was denied outright, call (215) 875-7030.
Our Philadelphia workers’ compensation page and workers’ comp FAQ cover the rest of how Pennsylvania claims run.
