Illinois Midwest Insurance Agency LLC v. Workers’ Compensation Appeals Bd. (Rodriguez) (2025) Cal.App.5th 1168; review granted Jan. 21, 2026, S294463
Review Granted — Opinion Pending Before the California Supreme Court
On January 21, 2026, the California Supreme Court granted review in Ill. Midwest Ins. Agency LLC v. Workers’ Comp. Appeals Bd. & Orlando Rodriguez (S294463). Pending review, the Court of Appeal’s opinion—currently published at 115 Cal.App.5th 1168—may be cited for its persuasive value and for the limited purpose of establishing the existence of a conflict in authority pursuant to California Rules of Court, rule 8.1115(e)(3). The Supreme Court’s ultimate disposition will determine the precedential status of the decision discussed below.
In Illinois Midwest Insurance Agency LLC v. Workers’ Compensation Appeals Bd. (Rodriguez) (2025) 115 Cal.App.5th 1168, the Second District Court of Appeal issued a sweeping clarification of California’s medical treatment dispute framework, squarely rejecting the long-relied-upon Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910 and restoring the primacy of Utilization Review (UR) and Independent Medical Review (IMR) for post-2013 medical-necessity disputes. The court held that the WCAB lacked jurisdiction to adjudicate a disagreement over home health care following a UR denial, emphasizing that IMR is the exclusive remedy under Labor Code section 4610.5(e). The court annulled the WCAB’s award of ongoing home health care services and remanded the matter. The opinion carries substantial implications for claims involving extended or continuing treatment such as home health, nursing, and attendant care services.
The case arose from a 2016 traumatic brain injury suffered by Orlando Rodriguez while employed as a mechanic. Beginning in September 2018, his primary treating physician, Dr. Yong Lee, requested home health care services in six-week increments. Illinois Midwest repeatedly authorized these requests, sometimes voluntarily and sometimes after submission to UR. According to the record, the insurer approved at least eight RFAs between September 2018 and August 2019, reflecting authorizations limited to the duration requested by the physician. (Rodriguez, supra, at pp. 1176-1177.)
In September 2019, Dr. Lee again sought authorization for an additional six-week period of home health care. The UR reviewer issued a timely denial on September 19, 2019, and communicated the decision to the physician, applicant, and applicant’s counsel. (Id.) Rather than pursue IMR, Rodriguez sought an expedited hearing before a workers’ compensation judge (WCJ), contending that his need for home health care was ongoing and that the insurer could terminate the treatment only upon proof of a material change in condition. The WCJ agreed, found the UR denial “moot,” and concluded that the WCAB retained jurisdiction because the need for care was ongoing. The WCJ relied heavily on Patterson, a significant panel decision often cited for the proposition that once ongoing treatment is authorized, it must continue absent proof of changed circumstances.
On reconsideration, the WCAB affirmed relying on Patterson’s reasoning. The Board concluded that the employer could not “place arbitrary time limits” on authorized treatment and that future RFAs for the same care were unnecessary unless the employer demonstrated a change in condition. The WCAB further suggested that the Court of Appeal had implicitly endorsed Patterson through prior summary denials of petitions for review. (Id. at pp. 1177-1178.)
The Court of Appeal rejected these conclusions. The opinion begins with a detailed review of the 2004 and 2013 legislative reforms, explaining that the Legislature deliberately removed medical-necessity determinations from litigation and placed them within a structured process grounded in evidence-based medicine and conducted by medical professionals. (Id. at pp. 1178-1183.) Labor Code section 4610.5(e) provides that a UR decision “may be reviewed or appealed only” through IMR. The court characterized this language as unequivocal and applicable to Rodriguez’s 2016 injury and the 2019 UR denial. Because IMR is the exclusive remedy, the WCAB lacked jurisdiction to adjudicate the dispute. (Id. at pp. 1183-1184.)
Turning to Patterson, the court explained that the case involved a pre-2013 statutory framework and a unilateral termination of services that had not proceeded through UR. (Id. at pp. 1184-1186.) The court concluded that Patterson was factually distinguishable and legally incompatible with the post-SB 863 statutory scheme. To the extent Patterson had been interpreted as creating an exception for “ongoing” treatment once previously authorized, that interpretation was expressly rejected. (Id. at pp. 1186-1187.)
The Court of Appeal further rejected the WCAB’s theory that previously authorized treatment becomes indefinitely authorized absent proof of changed circumstances. The court found no statutory language supporting such a burden-shifting framework. Instead, the statutory scheme contemplates new RFAs and periodic reassessments consistent with the Medical Treatment Utilization Schedule (MTUS). The court cited MTUS provisions requiring that home health care frequency and duration be individualized, documented in a treatment plan, and reassessed at regular intervals—underscoring that duration and continuing necessity are medical determinations entrusted to physicians, not adjudicators. (Id. at pp. 1187-1189.)
The court also clarified that summary denials of petitions for review have no precedential value and cannot be construed as appellate approval of Patterson. No published appellate decision had adopted Patterson’s reasoning, and the court declined to do so. (Id. at p. 1190.)
Ultimately, the Court of Appeal held that the WCAB acted in excess of its jurisdiction. Because Rodriguez did not pursue IMR following the UR denial, the WCAB had no authority to award ongoing home health care. The decision was annulled and the matter remanded. (Id. at p. 1191.)
Although review has now been granted by the California Supreme Court, the Court of Appeal’s reasoning currently provides significant guidance regarding the exclusivity of UR and IMR in disputes involving continuing medical treatment. The Supreme Court’s forthcoming opinion will determine whether that framework remains intact or whether any limitation on the scope of UR/IMR exclusivity will be recognized.
Article Written By: Rachel Fortner, Associate Attorney, Santa Rosa Office, Mullen & Filippi, February 16, 2026
