California: Utilization Review: Timelines for Expedited Review When Imminent and Serious Threat Exists

In Rodriguez v. Air Eagle, Inc., 2015 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB has provided guidance on the expedited review of a request for authorization and on the burden of proof of a prescription for home health care services.

UR Denial Timeline for Expedited Review

The WCAB, amending the WCJ’s decision, held that the defendant’s 11/6/2013 utilization review (UR) denial of the applicant’s request for home health care services for 24 hours per day, seven days per week on a psychiatric basis was untimely and, therefore, invalid under Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp. Cases 1298 (Appeals Board en banc opinion) (Dubon II).

The WCAB found that although the defendant’s UR decision was issued nine days after the receipt of Dr. Farshid Hekmat’s 10/28/2013 request for authorization (RFA) and was timely within the time requirements for a regular UR decision pursuant to former 8 Cal. Code Reg. § 9792.9.1, operative 10/1/2013, Dr. Hekmat checked the box on the RFA for “imminent and serious threat,” thereby raising the issue of whether the RFA was subject to timelines for an expedited review, which requires the UR decision to be issued within 72 hours of receipt of the information reasonably necessary to make the determination.

The WCAB pointed out that the defendant’s claims adjuster and UR reviewer both testified that the RFA was correctly filled out and was complete when it was received.

As explained by the WCAB, the purpose of the box check is to alert the UR reviewer that a separate timeframe for a decision applies, and that there is nothing in 8 Cal. Code Reg. § 9792.9.1 as it existed in 2013 that allows a defendant to override the requesting physician’s designation of the request as “imminent and serious.” Here, the WCAB found that under the circumstances, Dr. Hekmat’s RFA should have been treated as an expedited request. Thus, the request for further information regarding the duration of the requested home health care services sent by the UR reviewer to the defendant on 11/1/2013 did not meet the 72-hour timeframe, making the UR untimely.

Home Health Care Services

The WCAB, in a split decision, held that the applicant was entitled to home health care services by a psychiatric technician or a Licensed Vocational Nurse from 10/22/2013, and continuing indefinitely. The WCAB found that the applicant met his burden to prove that the 9/26/2013 report of Dr. Farshid Hekmat was a prescription under Labor Code § 4600(h) and Neri Hernandez v. Geneva Staffing, Inc. dba Workforce Outsourcing, Inc. (2014) 79 Cal. Comp. Cases 682 (Appeals Board en banc opinion).

The WCAB further found that the defendant received Dr. Hekmat’s prescription on 10/7/2013, and under Labor Code § 4600(h), was liable for treatment from 14 days before the date the prescription was received.

The WCAB explained that since the parties stipulated that the issue was whether the applicant was entitled to home health care services beginning on 10/22/2013, and the defendant received the prescription more than 14 days before that date, the defendant was potentially liable for home health care on the first day of the stipulated period.

The WCAB concluded that the applicant met his burden of proving with substantial medical evidence that the requested home health care services were reasonable and necessary to cure and relieve the effects of his industrial injury.

Commissioner Zalewski dissented and would find that the applicant did not meet his burden of showing he was entitled to home health care services from 10/22/2013 and continuing.

Read the Rodriguez noteworthy panel decision.

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