California Utilization Review: 24-Hour Extension of Time for Communicating UR Determination

WCAB finds UR untimely and defendant did not communicate UR determination initially by phone, fax or email as required by Rule 9792.9.1(e)(3)

In Rivera v. Valley Radiology, 2014 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB panel affirmed the WCJ’s finding that the applicant, who sustained an admitted industrial injury to her low back on 8/27/2010, was in need of further medical treatment in the form of acupuncture and medications (Flexeril, Norco, Neurontin, Terocin and Theramine medical supplement) as prescribed by her primary treating physician, Norman Kahan, M.D.

The WCAB held that independent medical review was not appropriate here because the defendant did not comply with the utilization review time limits in Labor Code § 4610(g)(1). According to the WCAB, the defendant received Dr. Kahan’s request for authorization no later than 7/8/2013 via facsimile but it did not issue the UR non-certification until 7/15/2013.

Although the defendant asserted that the UR provider was allowed an additional 24 hours after making a determination to communicate a written UR determination to the treating physician under Labor Code § 4610(g)(3)(A), the WCAB found that the defendant did not communicate its decision “initially by telephone, facsimile, or electronic mail” as required under 8 Cal. Code Reg. § 9792.9.1(e)(3) before it served the written notice of the UR determination on 7/15/2013. Thus, UR was untimely.

Read the Rivera noteworthy panel decision.

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