The worst-case outcome is a denied surgery, medication, or therapy plan because no one recognized that the insurer was questioning whether the care was medically necessary. Utilization review is the process a health insurer, workers' compensation insurer, or plan administrator uses to evaluate whether proposed, ongoing, or completed medical treatment is reasonable, necessary, appropriate, and sometimes cost-effective under the applicable coverage rules.

In practice, utilization review can happen before treatment through preauthorization, during treatment through concurrent review, or after treatment through retrospective review. The reviewer may look at medical records, treatment guidelines, work restrictions, and whether the care is related to the injury or illness being claimed. A negative utilization review decision can limit payment for care even when a treating doctor recommends it.

For an injury claim, utilization review often becomes a dispute over medical necessity, causation, and the insurer's duty to pay benefits. In a workers' compensation case, that can affect whether treatment continues, whether wage-loss periods are extended, and whether the worker can document disability. In Maine, medical-benefit disputes are generally governed by the Maine Workers' Compensation Act, including 39-A M.R.S. § 206, and are resolved through the Maine Workers' Compensation Board rather than by assuming a doctor's recommendation is automatically binding. If treatment is denied on review, the next step is often a formal petition for benefits or other Board proceeding challenging the denial.