You were injured at work. Your treating physician recommends surgery, physical therapy, or a specific medication to help you recover. Then you receive a letter from the insurance company stating that the recommended treatment has been “non-certified” through something called utilization review. The treatment your doctor says you need is being denied — not by another doctor who examined you, but by a reviewer who may have only read your medical records. If this has happened to you, you are not alone, and you have options under Illinois law.
What Is Utilization Review in Illinois Workers’ Compensation?
Utilization review — often referred to as “UR” — is a process that employers and their insurance carriers use to evaluate whether medical treatment recommended by your doctor is appropriate and medically necessary. Under Section 8.7 of the Illinois Workers’ Compensation Act (820 ILCS 305/8.7), employers may use a utilization review program, but that program must be registered with the Illinois Department of Insurance and must comply with nationally recognized accreditation standards, such as those established by URAC. The review itself must be conducted in accordance with evidence-based medicine and guidelines.
Utilization review can take several forms. Prospective review evaluates a treatment request before the services are provided. Concurrent review assesses treatment while it is already being rendered. Retrospective review examines care after services have been completed. In each case, a physician reviewer — who has not examined you in person — renders an opinion on whether the proposed or provided treatment meets recognized medical standards. It is worth noting that Section 8.7 does not apply to first aid or emergency treatment, meaning that truly urgent initial care should not be delayed by the UR process.
When a UR determination results in a “non-certification,” the insurance company uses that finding to deny or delay authorization for the treatment your doctor has recommended. For many injured workers, this feels like the insurance company is overruling their physician. Understanding how UR works — and its limitations — is the first step toward protecting your right to the medical care you need.
Your Employer’s Obligation to Provide Medical Care
Under Section 8(a) of the Illinois Workers’ Compensation Act, your employer is required to provide “all the necessary first aid, medical and surgical services, and all necessary medical, surgical and hospital services thereafter incurred to cure or relieve from the effects of the accidental injury.” This is a broad obligation, and it means that if treatment is reasonably necessary to help you recover from your work injury, your employer must pay for it.
A utilization review denial does not eliminate this obligation. Under Section 8.7(j), a UR report is admissible evidence that the Illinois Workers’ Compensation Commission (the “Commission”) considers along with all other evidence in the record — including the opinions of your treating physician, diagnostic imaging, and other medical documentation. A UR report is not the final word on whether you are entitled to treatment. The Commission retains full discretion to evaluate whether the UR findings are persuasive, and in many cases, the Commission has found the opinions of treating physicians more credible than those of UR reviewers — particularly when the UR reviewer is not in the same medical specialty as the treating doctor or when the review lacks a thorough clinical rationale.
What to Look for in a Utilization Review Denial
Not all utilization review reports are created equal. Under Section 8.7(i)(2) of the Act, a UR non-certification must include a written notice containing the clinical rationale for the denial and references to the applicable standards of care or evidence-based medical guidelines relied upon. If these elements are missing or inadequate, the UR report may carry little persuasive weight before the Commission.
Pay close attention to the specialty of the reviewing physician. If your treating orthopedic surgeon recommends a shoulder surgery and the UR denial comes from a physician who does not specialize in orthopedic surgery, that mismatch can significantly undermine the credibility of the denial. While the Illinois Workers’ Compensation Act does not expressly mandate a same-specialty requirement for the initial UR review, Illinois insurance regulations and accreditation standards generally require that appeal-level reviews be conducted by physicians in the same or similar specialty as the treating provider. This is a factor the Commission considers when deciding how much weight to give a UR determination.
The UR Appeal Process and Your Right to a Hearing
If your treatment is denied through utilization review, you do not have to accept that decision. Section 8.7 contemplates a grievance and appeal process for non-certifications. During an appeal, the UR program may consider additional medical evidence, and the review should be conducted by a qualified physician. Your treating physician plays a critical role in this process. A peer-to-peer discussion between the UR reviewer and your doctor can sometimes resolve the dispute without the need for litigation. Your doctor may also submit additional medical records, updated imaging, or a detailed narrative explaining why the recommended treatment is necessary for your specific condition.
If the appeal does not resolve the dispute — or if the insurance company continues to refuse to pay for treatment — you have the right to file a petition under Section 19(b) of the Act for an expedited hearing before the Commission. A Section 19(b) petition allows you to bring the medical dispute before an arbitrator who can determine whether you are entitled to the recommended treatment under Section 8(a). In cases involving truly urgent medical needs, Section 19(b-1) provides for an emergency hearing, which can result in even faster relief. These expedited procedures exist specifically so that injured workers do not have to wait months or years for a final resolution while their medical conditions worsen.
One important legal reality to understand: under Section 8.7(i)(4), once treatment is denied through utilization review, the burden shifts to the injured worker to prove by a preponderance of the evidence that a variance from the UR standard is reasonably required. This means that if the insurance company has obtained a properly conducted UR denial, you will need to present persuasive medical evidence — typically from your treating physician — demonstrating why the recommended treatment is necessary despite the UR findings. Recent Commission decisions have reinforced this framework. In Alcaraz-Garcia v. Labor Solutions, LLC, 25 I.W.C.C. 0442 (2025), the Commission vacated payment for physical therapy sessions that exceeded the UR standard where the injured worker failed to present evidence justifying a variance. Conversely, in Bell v. Amazon, 25 I.W.C.C. 0352 (2025), the Commission noted that medical bills already paid by the employer carry a presumption of reasonableness even when the treatment has been scrutinized by utilization review. These decisions underscore the importance of working with an experienced attorney who can build a strong medical record to support your treatment needs.
Protecting Your Right to Medical Treatment
If you have received a utilization review denial, there are several important steps to keep in mind. First, do not assume that the denial is final. You have the right to appeal through the UR program’s internal process, and you have the right to seek an expedited or emergency hearing before the Commission if necessary. Second, communicate with your treating physician about the denial. Your doctor can provide additional documentation, request a peer-to-peer discussion with the UR reviewer, or submit a detailed narrative explaining why the recommended treatment is necessary for your recovery. Third, be aware that a utilization review is not the same as a Section 12 independent medical examination. A UR reviewer does not examine you in person — the reviewer evaluates records and applies medical guidelines. Your treating physician, who has examined you, knows your condition, and has followed your progress, often has a more complete picture of what treatment you need.
If the insurance company is refusing to pay for treatment that your doctor says is necessary, do not wait. Delays in medical care can affect both your recovery and the strength of your workers’ compensation claim.
If you have been injured at work and the insurance company has denied medical treatment recommended by your doctor, the attorneys at The Law Offices of Millon & Peskin, Ltd. can help. We represent injured workers throughout the Chicagoland area, including DuPage, Cook, Will, Kane, and Lake counties, and we have extensive experience handling disputes over medical treatment and utilization review denials. Contact us today at 630-449-3884 for a free consultation to discuss your rights and your options. You can also learn more about our workers’ compensation practice and the types of cases we handle.