Utilization Review Requirements

(1) In any case in which utilization review is undertaken, the utilization review organization shall make an objective evaluation of the recommended treatment as it relates to the employee’s condition and render a determination concerning the medical necessity of the recommended treatment. A utilization review agent shall contact the authorized treating physician regarding the recommended treatment pursuant to applicable law and Rule 0800-02-06-.06; provided that such contact shall not constitute a waiver of any other applicable privilege or confidentiality. (2) Upon initiation of utilization review, the authorized treating physician shall submit all necessary information to the utilization review organization and shall certify that the information is a complete copy of the health care provider’s records and reports that are necessary for utilization review. The authorized treating physician shall also include the reason(s) for the necessity of the recommended treatment in such records and reports. The employer, or other payer, shall reimburse the authorized treating physician for the costs of copying and transmitting such records; provided that the costs do not exceed the amounts prescribed by T.C.A. § 50-6-204. If a dispute arises as to the completeness or necessity of information, then the parties shall proceed as set forth in Rule 0800-02-06-.06(5). (3) Upon receipt of all necessary information, the initial utilization review decision may be determined by a licensed registered nurse whenever the recommended treatment is being approved. For all denials, the utilization review decision shall be determined by a utilization review physician and communicated to the parties in a written utilization review report. (4) Any treatment that explicitly follows the Treatment Guidelines, including medications, adopted by the administrator or is reasonably derived therefrom, including allowances for specific adjustments to treatment, shall have a presumption of medical necessity for utilization review purposes. This presumption shall be rebuttable only by clear and convincing evidence that the treatment erroneously applies the guidelines or that the treatment presents an unwarranted risk to the injured worker. (5) If a question arises in a Utilization Review denial, as to whether a recommended treatment follows the guidelines adopted by the administrator or is reasonably derived therefrom, including allowances for specific adjustments to treatment, or that the treatment erroneously applies the guidelines, or that the treatment presents an unwarranted risk to the injured worker, then the employee or authorized treating physician may appeal the Utilization Review GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW denial, and the Medical Director will make a written determination and communicate that determination in accordance with the provisions in 0800-02-06-.07.