Key takeaways
Utilization review is a medical-authorization process; the important documents are the treatment request, review decision, and appeal instructions.
Records to put together
- Treatment request
- Utilization-review decision
- Medical records cited
- Official appeal/review instructions
Questions to verify
- What medical rationale is stated?
- Was required information missing?
- Can the provider supplement the request?
- What deadline controls review?
Important caution
Utilization-review procedures are highly state-specific.
When a lawyer consultation may help
- A deadline, hearing, denial, or benefit change is close or disputed.
- The medical evidence and the insurer/employer position conflict.
- Permanent restrictions, settlement, third-party liability, employment status, or retaliation may affect the file.
What to compare in a utilization-review decision
- The exact treatment requested by the treating provider.
- The diagnosis, accepted body part, and clinical findings sent with the request.
- Whether the decision approves, modifies, delays, or denies each requested item.
- The guideline, rationale, reviewer information, and review instructions stated in the letter.
- The date the decision and any review form were received.
Procedures differ by state. For example, California explains utilization review and its independent medical review process on the DWC utilization review page and DWC independent medical review page. Use the agency for the state handling your claim.