California: WCJ Sounds Off on UR/IMR Process - Loynachan v. County of Los Angeles

California: WCJ Sounds Off on UR/IMR Process - Loynachan v. County of Los Angeles

In Loynachan v. County of Los Angeles, ADJ7144283, the WCJ held that the applicant, who was permanently totally disabled as a result of a 10/1/2009 industrial injury, was entitled to continue receiving 24 sessions of behavioral psychotherapy each year for his mild traumatic brain and cognitive injury, as prescribed by his treating psychiatrist and recommended by the parties’ psychiatric agreed medical examiner.

The WCJ found that the UR modification of prescribed psychotherapy treatment to include only 6 annual sessions instead of 24 sessions, which was affirmed by the IMR, was based on a mistake of fact and, therefore, invalid, because the UR, although determining that psychotherapy was medically necessary, improperly questioned the relationship of the requested treatment to applicant’s industrial injury despite the determination by applicant’s treating psychiatrist and agreed medical examiner that his brain injury and its neurological consequences were related to his industrial injury.

The WCJ further found that the UR modification and the IMR affirmation of the modification were also invalid on the basis that they were not consistent with the workers’ compensation standard entitling an applicant to reasonable and necessary medical treatment to “cure or relieve” from the effects of industrial injury, because both determinations found that the recommended psychotherapy sessions were unjustified in that they would not result in a complete cognitive function or have a lasting benefit, and the determinations ignored the medical opinions of the treating psychiatrist and the agreed medical examiner that the treatment was helping applicant make “slight progress” towards cognitive improvement and was preventing the further deterioration of his cognitive skills.

As stated by the WCJ, the IMR’s finding that applicant’s neurological deficits were interfering with the effectiveness of his psychotherapy sessions was demeaning and contrary to the Official Disability Guidelines.

The implementation of the UR and IMR procedures for resolving medical disputes create substantial delay and severely limit or deny injured workers’ access to necessary medical care, in contravention of the principles and purpose underlying the workers’ compensation system, according to this WCJ.

Read the judge's opinion on decision here.

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