Drug Utilization Review Checklist for Personal Injury Attorneys

James Wong — Founder & Pharmacist, LienScripts | May 9, 2024 | 8 min read

A drug utilization review (DUR) is the process of verifying that every medication in a lien is clinically appropriate for the injury, prescribed by a qualified provider, and free of duplication or red flags. PI attorneys who understand DUR can catch problems before the defense does — and build a cleaner, more defensible demand.

This post is for informational purposes only and does not constitute legal advice.

What Is a Drug Utilization Review?

A drug utilization review (DUR) is a structured evaluation of a patient's medication regimen to confirm that prescriptions are appropriate, necessary, and free of clinical or administrative errors. Pharmacists perform DURs routinely before dispensing medications. PI attorneys should perform their own DUR before including a pharmacy lien in a demand package.

Why? Because insurance adjusters and defense counsel conduct their own DUR-style review of pharmacy records. Any red flag they identify — a medication with no clinical basis, a duplicate of a prior prescription, an unusually high dose, a medication with no apparent connection to the injury — becomes a basis to dispute the lien and reduce the settlement valuation.

A pre-demand DUR lets you find and address those issues first.

[!KEY] A DUR is not just a clinical tool — it is a pre-litigation risk management step that lets you find and address the same red flags the defense will raise, before your demand goes out.

The DUR Checklist for PI Attorneys

Work through each category systematically before your demand goes out.

Category 1: Indication Appropriateness

Each medication should have a clear clinical indication that ties to the injury.

• Every medication on the lien has a documented injury-related diagnosis code in the treating physician's notes
• The medication class matches the diagnosis (e.g., NSAIDs or muscle relaxants for soft tissue injury; nerve agents for radiculopathy; CGRPs for post-traumatic migraine)
• No medications are listed with diagnoses that appear pre-existing and unrelated to the injury
• Controlled substances (opioids, benzodiazepines) are supported by a clinical rationale beyond just the class; the treating physician's notes document the pain level, functional limitation, and the basis for prescribing
• Specialty medications (biologics, infusion medications, CGRP inhibitors) have documentation of why first-line options were inadequate

Category 2: Prescriber Qualifications

• Every medication was prescribed by a licensed provider authorized to prescribe that drug class in California
• Controlled substances were prescribed by a physician with a valid DEA number (not a PA or NP if prescribing beyond their scope)
• Specialty medications were prescribed by the appropriate specialist (e.g., neurologist for migraine medications, psychiatrist for psychiatric medications)
• Prescriptions were not written by a provider with a financial relationship to the pharmacy that could raise conflict-of-interest concerns

Category 3: Dosing Appropriateness

• The dose prescribed falls within standard clinical ranges for the diagnosis
• High-dose prescriptions (e.g., gabapentin >1,800 mg/day) are supported by documentation of the clinical need (severity of neuropathic pain, documented failed response to lower doses)
• Long-duration prescriptions are supported by follow-up notes showing ongoing clinical need
• No significant changes in dosing that lack a corresponding clinical note explaining the change

Category 4: Duplication and Overlap

• No therapeutic duplicates (two medications in the same class prescribed simultaneously without clinical explanation)
• No overlap between the lien medications and medications the client was taking before the accident for the same indication
• No overlap between lien medications and medications covered by the client's health insurance for the same condition
• If the client changed pharmacies during treatment, there are no duplicate fills for the same medication from two sources covering the same date of service

Category 5: Timeline Integrity

• No medications were dispensed before the accident date
• The first prescription issue date follows logically from the injury date (typically within the first 30 days)
• Prescription gaps are documented and explained (see the treatment gap documentation guide)
• No medications continue past the documented end of treatment without a clinical note supporting ongoing need

Category 6: Administrative Accuracy

• The lien balance statement reflects the same medications and fills shown in the dispense history (no billing for medications not dispensed)
• The patient name, date of birth, and injury date on the lien documents match the client's case file
• All prescriptions were filled under the lien agreement — no prior-fill costs inadvertently included

[!TIP] If the DUR finds a medication that cannot be connected to the injury, work with LienScripts to remove it from the lien balance — a smaller, fully defensible lien is more valuable at settlement than a larger one with contested items.

[!KEY] Therapeutic duplicates — two medications in the same class prescribed simultaneously without clinical explanation — are the most common basis for adjuster challenges to pharmacy liens; catching and addressing them before the demand goes out prevents a credibility problem at the worst possible time.

What to Do When You Find a Red Flag

If the DUR identifies a potential issue, do not simply leave it unaddressed. Options include:

Request clarification from the prescribing provider. A brief provider note explaining the clinical basis for an unusual medication or high dose is the most effective resolution.

Remove the medication from the lien. If a medication cannot be connected to the injury — or if it appears to reflect a pre-existing condition — consider working with LienScripts to remove it from the lien balance. A cleaner lien is more defensible than a larger one with questionable items.

Address it proactively in the demand narrative. If the issue cannot be fully resolved but has a good explanation, present that explanation in the demand. Do not let the defense discover it and frame it on their terms.

Consult with the treating pharmacist or a clinical expert. For complex medication regimens, a pharmacist's brief written assessment of clinical appropriateness can neutralize challenges to the regimen.

[!KEY] Controlled substance prescriptions without clinical documentation of pain level, functional limitation, and the physician's basis for prescribing will face the most aggressive defense scrutiny — ensure those chart notes are in your file before the demand goes out.

Key Takeaway

A DUR is not just a clinical tool — it is a pre-litigation risk management tool. By reviewing your client's pharmacy lien through the same lens that the defense will use, you identify and resolve issues before they become settlement obstacles. LienScripts provides dispense histories and MERIT reports that give you the raw data; the DUR checklist tells you what to look for and what to do about it.