California: The RFA as well as the Accompanying Documentation Must Be Considered

Recently, a panel of commissioners with the Workers’ Compensation Appeals Board (WCAB) addressed a medical treatment dispute where the question was what documentation had to be considered by the claims adjuster in reviewing a treatment request (Ives v. DR Myers Distributing Company, 2018 Cal. Wrk. Comp. P.D. LEXIS --). On the RFA form, the requesting provider listed eight sessions of chiropractic care, however, in the medical report attached to the RFA, a narrative report actually expanded on the recommendation by elaborating that there was a specific doctor who is a specialist in chiropractic neurology who would provide the optimal treatment for the injured worker. In response, defendant merely authorized eight chiropractic visits with a chiropractor in its Medical Provider Network (MPN).

The panel concluded that the defendant’s authorization of just chiropractic treatment with a chiropractor within its MPN was an improper modification of the requested treatment. Indeed, citing first to Title 8, California Code of Regulations, section 9792.6.1(t)(2), which provides the treating physician must attach documentation substantiating the need for the requested treatment, the panel then referred to Labor Code Section 4610(e) and found that only a licensed physician can modify, delay or deny requests for authorization. It must be a reviewing physician, and not the claims adjuster, who is responsible for applying the Medical Treatment Utilization Schedule (MTUS) when determining medical necessity.

This line of reasoning is important to the extent that it finds that the RFA and attached report must be read as a whole. In the words of the panel, it must be read as “one package”. Should the adjuster only skim the first page of RFA and authorize what he or she believes is being requested, should the attachments indicate that something altogether different is, in fact, being requested, the adjuster may have just waived the defendant’s right to pursue UR on the requested treatment.

This case is a “heads-up” to all of the claims adjusters to read all of the documents being submitted by the treating physician when an RFA is submitted. Should the attached documents support a treatment request that is neither authorized nor placed through UR, it may become a Dubon II issue and may come down to the WCALJ determining whether the requested treatment is supported by substantial evidence.

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