Case BriefUtilization Review / IMRDefendants Utilization Review Obligation is Not Triggered Absent a Request for Authorization

March 10, 20160


(2015) 2015 Cal Wrk. P.D. Lexis 596

Applicant sustained various injuries while working as an anesthesia technician. The injuries resulted in 100% permanent disability. In November 2013, the applicant had a walk-in bathtub installed because of stability issues which resulted in several falls. In addition, the tub had hydrotherapy jets which the applicant believed helped with her pain relief.

On December 20, 2013, the applicant had an appointment with her treating physician. In his PR-2, the doctor noted that the applicant had installed the walk in tub and that he “supported” her use of the walk-in tub. However, he did not state that he was requesting authorization for the tub, nor did the doctor check the box on the report identifying a “Request for Authorization”. Also, the report was not accompanied by a separate Request for Authorization form.

On February 5, 2014, the doctor issued a prescription to the applicant for the walk-in tub. Applicant’s attorney first provided the prescription to the defendant on March 24, 2015. The prescription did not identify it as a Request for Authorization nor did the accompanying PR-2 form have the Request for Authorization box checked. The defendant did not conduct a Utilization Review of the prescription for the walk-in tub.

Applicant filed for a hearing on the medical treatment issue. The Workers Compensation Judge found that the defendant was liable for the $13,000.00 cost of the self-procured tub, citing Braewood Convalescent Hospital vs. WCAB for the proposition that defendant had a duty to investigate the need for medical treatment.

Defendant filed a Petition for Reconsideration, arguing that it had no obligation to conduct Utilization Review because there was never a Request for Authorization from the treating physician. The petition was granted.

The Commissioners noted that “The Utilization Review process begins when the completed DWC form RFA, or a Request for Authorization accepted as complete under §979 2.9.1(c)(2), is first received by the claims administrator”. In this case, the treating physician has not submitted a Request for Authorization.

The Board noted that a defendant may have a duty to expend an active degree of effort to provide medical treatment. However, an applicant also has a duty to expend some degree of effort to request medical treatment.

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