Case BriefUtilization Review / IMRDefendant Must Conduct Timely Retrospective Utilization Review Once Liability for Injury is Established

March 10, 20160


(2015) 2015 Cal. Wrk. Comp. P.D. Lexis 738

Applicant was an employee of United Parcel Service who claimed multiple injuries including intracranial hemorrhage, hypertension, sleep disorder, vision and psyche through August 2006. Defendant denied the claims. After several years of litigation, the case was tried and the injuries were found to be compensable on April 12, 2013. The defendant filed a Petition for Reconsideration which was denied on June 21, 2013.

During the course of the litigation, applicant’s physicians had requested a number of treatments including home health care on a 24/7 basis; nurse case manager; transportation services; stroke rehabilitation; home modification assessment; an electric wheelchair; and a roll-in van.

The defendant eventually submitted these requests for retrospective Utilization Review on January 28, 2014. On February 4, 2014, the requested treatment was non-certified.

The applicant requested a hearing on the issue of medical treatment. The Workers’ Compensation Judge determined that the Utilization Review was not timely. Therefore, the Utilization Review determination was invalid and he could determine the necessity of the medical treatment. He found in favor of the applicant and awarded the treatment.

The defendant filed a Petition for Reconsideration which was denied.

While the defendant was not required to conduct Utilization Review of the doctor’s treatment recommendations while it was disputing liability (Labor Code §4610(g)(7)), it was required to conduct Utilization Review immediately upon the date the determination of its liability became final. Here, the determination of defendant’s liability became final on June 21, 2013 (the date its Petition for Reconsideration of the AOE/COE decision was denied). However, it did not submit the treatment requests to Utilization Review until January 28, 2014, more than seven months later. Consequently, the Utilization Review decision was not timely and the Workers’ Compensation Judge had jurisdiction to decide the treatment issue.

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