Revised 1/8/10



Ordering Provider's Full Name
Street Address
City, MA Zip Code

RE: Patient Name:
Claim Number:
Injury Date:
UR File Number:

Dear Dr. [Provider's Full Name]:

Massachusetts workers' compensation insurers are required to undertake utilization review of health care services provided to injured workers in accordance with the Utilization Review and Quality Assessment Regulation (452 CMR 6.00). The Commonwealth of Massachusetts Department of Industrial Accidents has approved [UR Agent] to conduct utilization review on Massachusetts workers' compensation cases.

This letter shall notify you that [UR Agent] has reviewed your appeal and a school to school reviewer, who was not involved with the initial adverse determination, has upheld the original adverse determination. Therefore the requested plan of treatment/service is Denied:

Treatment/Service Requested:
Clinical Rationale (include pertinent medical information):
Reviewed By: practitioner name and school of licensure

In accordance with 452 CMR 6.04, the appeal process with [UR Agent] has now been exhausted. You have the right to file a claim or complaint with the Department of Industrial Accidents in accordance with 452 CMR 1.07 under the provisions of Massachusetts General Laws Chapter 152. You may obtain the necessary forms by calling the DIA at (617) 727-4900 or by accessing the DIA website at

Please contact me at if you have any questions regarding this determination at [toll free number].



UR Agent Name/Title

CC: Injured Worker
Adjuster Name/ Company