04 Oct 2012

California: Disputing Utilization Review Denial of Authorization

This California WCAB panel decision will be added soon to the LexisNexis services. Note: This decision clarifies a prior decision, which we reported in our 6/13/2011 enewsletter:

Medical-Legal Procedure; Utilization Review; Spinal Surgery. WCAB, rescinding its prior decision and granting reconsideration on its own motion [see Corona v. Los Aptos Christian Fellowship Childcare, 2011 Cal. Wrk. Comp. P.D. LEXIS 156], affirmed WCJ’s finding that that applicant/pre-school teacher was in need of further medical treatment to cure or relive effects of her neck, back, wrist and psyche injuries during period 1986 to 2006, and held that (1) an employee is obligated to object and follow UR process set forth in Labor Code § 4062 if she disputes UR denial of authorization, (2) when treatment request is supported by substantial medical evidence it is also appropriate for injured worker to challenge UR based upon procedural deficiencies at an expedited hearing pursuant to Labor Code § 5502(d), as occurred in this case, and (3) if UR process is properly and timely followed but there is still a bona fide medical treatment dispute, it would not be proper to present dispute to a WCJ for determination at an expedited hearing without first obtaining medical evaluation as described in Labor Code § 4062.1 or Labor Code § 4062.2, depending on whether injured worker is represented; in those instances required medical evaluation by an Agreed Medical Examiner or panel Qualified Medical Evaluator may be accomplished by review of relevant documents if the physician has previously examined injured worker and concludes that another examination is unnecessary, unless an exception applies under Labor Code §§ 4062.3(j), 4067 or otherwise. See Corona panel decision.