Glossary Check: Tenn. 'Utilization Review'

01 Feb, 2023 Frank Ferreri

                               

Nashville, TN (WorkersCompensation.com) -- The utilization review process is a part of the workers' compensation system in most states that makes determinations about an injured worker's ongoing medical treatment.

One of those states is Tennessee, which, not surprisingly, defines the process and aspects of it via state workers' compensation law. Here's a look at those definitions from the Volunteer State.

Utilization Review

  • A system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual.
  • “Utilization review” does not include elective requests for clarification of coverage.

Utilization Review Agent

  • Any person or entity, including the state, performing utilization review, except:
    • An agency of the federal government.
    • An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government.
    • A hospital's internal quality assurance program.
    • An employee of a utilization review agent.
    • Health maintenance organizations licensed and regulated by the commissioner, but only to the extent of providing utilization review to their own members.
Notable Case
 
In Walker v. G. UB. MK Constructors, 2016 WL 2343177 (Tenn. 05/02/16), Tennessee's Supreme Court explained that an affidavit of a non-treating doctor from the utilization review process, which found that a worker's treatment was not medically reasonable or necessary, was sufficient to rebut the presumptin that the treatments ordered by the treating doctor were necessary.
 
Why?
  • In the utilization review process, the non-treating doctor reviewed "the pertinent medical records and reports."
  • Each doctor in the utilization review process concluded that trigger point injections, percutaneous neuromodulcation therapy, and aquatic thereapy were not medically reasonablly or necessary.

Find compliance information from Tennessee and the rest of the U.S. on WorkCompResearch


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    About The Author

    • Frank Ferreri

      Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law.

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