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California: WCAB Says MPN Treatment Requests Are Subject to UR/IMR

September 19, 2014 (2 min read)

Legislature did not demonstrate an intent to preclude employers from seeking UR of MPN physicians’ requests for authorization of medical treatment

In Stock v. Camarillo State Hospital, 2014 Cal. Wrk. Comp. P.D. LEXIS --, a WCAB panel held that the defendant’s utilization review (UR) determination of a request for authorization for a hospital bed submitted by a treating physician in the defendant’s medical provider network (MPN) was admissible over the applicant’s objection that the report should not be admitted on the basis that the defendant was not permitted to contest any medical treatment prescribed by MPN physicians.

The WCAB found that, contrary to the applicant’s assertion, the Legislature did not demonstrate an intent to preclude employers from seeking UR of MPN physicians’ requests for authorization of medical treatment. The statutory and regulatory law governing UR and MPN provisions provide that a treating physician’s request for authorization of medical treatment must be reviewed by a physician competent to evaluate the specific medical issues, without distinction as to whether the treating physician is selected through an MPN.

Furthermore, the definition of “primary treating physician” in 8 Cal. Code Reg. §§ 9767.1 and 9785(a)(1) both include physicians within an MPN. When an employer does not approve a treatment request from an applicant’s “primary treating physician,” the defendant must refer the request to UR.

According to the WCAB, further review of the treating physician’s request for a hospital bed to cure or relieve the effects of the applicant’s back injury must occur through independent medical review. The UR denial was based upon “silence” in the Medical Treatment Utilization Schedule guidelines, and the absence of “high quality studies” and “exceptional factors” in the documentation submitted to consider this request as an outlier to the guidelines. Moreover, it did not appear to consider other standards applicable in reviewing requests for authorization (i.e., nationally recognized professional standards, expert opinion, generally accepted standards of medical practice, and treatments that are likely to provide benefit for the condition for which other treatments are ineffective) as there was insufficient documentation or explanation provided to support the effectiveness of treatment in the form of a hospital bed.

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Commentary by Robert G. Rassp:

This case fails for the Applicant for two reasons.  First, it is clear that the legislature did not intend to create two separate classes of medical treatment providers—MPN physicians who are not subject to utilization review, and everyone else who is. Secondly, legal representatives of injured workers must always remember that there are two prongs in challenging a utilization review denial, modification, or delay of requested treatment, no matter who the requesting physician is: first, that the utilization review process was materially flawed, and second, that the requested treatment (here, a hospital bed for a bad back) is within the medical treatment utilization schedule or along the hierarchy of strength of evidence of medical necessity required under Labor Code Sections 4600(b), 5307.27, and 4610.5(c)(2). The requesting physician in this case should have attached some medical authority for his prescribing a hospital bed in this case to justify the whole thing.

Read the Stock noteworthy panel decision.

For earlier discussion of this topic, see the Hogenson article.