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Utilization review (UR) is the process used by employers or their insurance companies to review treatment requested by your treating doctor to determine whether it is medically necessary.
The treatment recommended by your doctor must be based on specific medical treatment guidelines. Based on the determination of the doctors that perform the utilization review, your adjuster will decide whether or not to approve the treatment that your doctor is recommending. Unfortunately, just because your treating doctor believes that you need certain medical treatment or that he needs certain testing to find out what is wrong with you, does not mean that the treatment or testing is absolutely necessary.
For example, if your doctor is requesting surgery, and he has not tried other treatment that might take care of your problem such as physical therapy, the doctor who performs the utilization review may say that your doctor needs to try that first and deny the surgery at that point in time. Other times, the utilization review doctor may request additional information from your doctor to help him decide if the treatment that he is requesting is medically necessary, but he may not get a response from your doctor. Talk to your doctor or your adjuster and find out exactly why UR denied your surgery. You may want to challenge (or appeal) the UR determination through a process known as Independent Medical Review (IMR). Your adjuster is required to send IMR forms to you along with a notice telling you that UR denied your treatment.
All employers or their insurance companies are required by law to have a UR program.
If you have questions about treatment for your workers' compensation injury and want to talk to an attorney in Fresno, please call 559-408-7436 or fill out the form to the right.