What is Utilization Review?

In Connecticut, an employer may have a workers’ compensation insurance policy that has a unitization review component. This is a procedure by which the workers’ compensation carrier can review a recommendation by a treating physician for a particular procedure such as a diagnostic test or a surgical procedure after the treating physician has ordered it.

A typical scenario is as follows: the claimant sustains a compensable lumbar spine injury which has not responded favorably to several months of physical therapy and anti-inflammatory medication. The treating physician requests authorization for an MRI. The workers’ compensation carrier will refer that request to the unitization review decision of its company and a nurse and/or doctor will review this request. Typically a “peer to peer” conference is requested with the doctor to get his or her feedback as to why this procedure is being requested.

Because of the time constraints placed upon the treating physician, it may be difficult or impossible for this physician to get back to the utilization review nurse or doctor. If two such attempts by utilization review are made without contacting the treating physician, the utilization review will summarily deny the procedure. This denial can be appealed, but ultimately, should the utilization review division stand on its denial throughout the various appeals of offices within the utilization review rules, there is nothing that can be done to overturn this decision by the workers’ compensation commissioner. However, the adjuster has the power to override the utilization review’s decision if he/she believes that the circumstances warrant it, or if a convincing argument can be made to the adjuster to do so.

One can check with the Chairman’s office in Hartford to determine whether a utilization review or division exists for a particular employer. This should be done by the claimant or the attorney once the spectre of utilization review has been raised.

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