Correa, Silvia

Treating physician Dr. Shamie submitted an RFA on February 16, 2024 marked for expedited review, requesting an increase in home caregiver assistance to 12 hours per day, seven days per week, for six months, plus medical transportation. Defendant Travelers issued a non-certification UR decision on February 21, 2024, treating the request under the standard five-business-day timeframe rather than the 72-hour expedited timeframe. The WCJ found the UR untimely because no medical professional reviewed the request within 72 hours, and found the requested treatment medically necessary. The Board affirmed, holding that the determination of whether expedited review is warranted is an inherently medical determination that must be made by a medical professional within the 72-hour expedited window, not retroactively by a claims administrator. The Petition for Reconsideration was denied.