34 Pa. Code § 127.472

Current through Register Vol. 50, No. 49, December 5, 2020
Section 127.472 - Duties of reviewers-content of records

The written reports of reviewers shall contain, at a minimum, the following elements: a listing of the records reviewed; documentation of any actual or attempted contacts with the provider under review; findings and conclusions; and a detailed explanation of the reasons for the conclusions reached by the reviewer, citing generally accepted treatment protocols and medical literature as appropriate.

Notes of Decision

Burden of Proof

Report filed by physician who performed utilization review did not comply with regulation requiring report to contain detailed explanation of reasons for conclusion that treatment by provider was not reasonable or necessary; burden of proof was on reviewer to provide details explaining his conclusion and statement that provider failed to convince him that treatment was reasonable and necessary failed to meet the reviewer's burden of proof. Sweigart v. W.C.A.B. (Burnham Corp.), 920 A.2d 962, 965-966 (Pa. Cmwlth. 2007)

34 Pa. Code § 127.472