127.1 Any medical care or service furnished or scheduled to be furnished under the Act shall be subject to utilization review. The review may be performed before, during, or after the medical care or service is provided.127.2 A utilization review organization or individual used pursuant to the Act shall be certified by the Utilization Review Accreditation Commission.127.3 The claimant or the Program may initiate utilization review where it appears that the necessity, character, or sufficiency of medical services is improper or clarification is needed on medical service that is scheduled to be provided.127.4 The necessity, character or sufficiency of medical services should be reviewed for treatment of the accepted condition(s) only.127.5 If a review of medical care or a service is initiated under this section, the utilization review organization must make a decision no later than sixty (60) days after the utilization review is requested. If the utilization review is not completed within one hundred-twenty (120) days of the request, the care or service under review shall be deemed approved.127.6 The report of the review shall specify the medical records considered and shall set forth rational medical evidence to support each finding. The report shall be authenticated or attested to by the utilization review individual or by an officer of the utilization review organization. The report shall be provided to the claimant and the Program.127.7 Any decision issued by the utilization review organization under this section shall inform the claimant of his or her right to reconsideration or appeal of the decision.127.8 A utilization review report which conforms to the provisions of this section shall be admissible in all proceedings with respect to any claim to determine whether medical care or service was, is, or may be necessary and appropriate to the diagnosis of the claimant's injury.127.9 If the medical care provider or claimant disagrees with the opinion of the utilization review organization or individual, the medical care provider or claimant may submit a written request to the utilization review organization or individual for reconsideration of the opinion.127.10 The request for reconsideration shall:- (a) Be in writing;

(b) Contain reasonable medical justification;

(c) Provide additional information, if the medical care or service was denied because insufficient information was initially provided to the utilization review organization; and

(d) Be made within sixty (60) calendar days of the claimant's receipt of the utilization review report if the claimant is requesting reconsideration, or within sixty (60) calendar days of the medical provider's receipt of the utilization review report, if the medical care provider is requesting reconsideration.

127.11 Disputes pursuant to Section 2323(a-2)(4) of the Act may be resolved upon an application for a hearing before the OAH within thirty (30) days of the date of the utilization review report or reconsideration decision.

127.12 Requests for a hearing pursuant to § 127.11 of this chapter may be made by the Program, medical provider, or claimant.

127.13 The Superior Court of the District of Columbia may review the OAH's decision without an appeal to the Compensation Review Board. The decision may be affirmed, modified, reversed, or remanded at the discretion of the court. The decision shall be affirmed if supported by substantial competent evidence of the record, pursuant to the District of Columbia Superior Court Rules of Civil Procedure Agency Review.

127.14 The District of Columbia government shall pay the cost of a utilization review if the claimant seeks the review and is the prevailing party.

SOURCE: Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amended by Emergency and Proposed Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 12224, 12229 (December 24, 2010); as amended by Final Rulemaking published at 59 DCR 8766, 8771 (July 27, 2012); as amended by Final Rulemaking published at 64 DCR 6325 (July 7, 2017).