Frausto v. Domestic Linen Supply 2024 Cal. Wrk. Comp. P.D. LEXIS 442 is a reminder that before terminating authorized medical treatment, a defendant has an affirmative burden to show that the continued provision of the services is no longer reasonably required due to a material change in the applicant’s condition or circumstances. Moreover, the submission of a Request for Authorization (RFA) for ongoing care that was previously authorized will be considered invalid absent a precipitating change in circumstance.
Applicant, a driver for Domestic Linen Supply, sustained injuries to his head, brain, eyes, ears, back, face, neck, right foot, teeth (TMJ) and developed a sleep disorder, urological dysfunction, and sexual dysfunction as a result of being ejected from a truck during a rollover motor vehicle accident on October 19, 2018. Applicant’s treatment at Center for Neuro Skills (CNS) was certified as medically necessary on February 2, 2023, April 26, 2023, June 29, 2023, and November 14, 2023. On April 1, 2024, the CNS treating physician authored a RFA diagnosing a Traumatic Brain Injury (TBI) and requesting authorization for continued outpatient care at CNS. On April 10, 2024, defendant’s UR provider issued a determination that continued treatment at CNS was not medically necessary. The rationale for the decision noted there had been “very little improvement over all areas tested.” Further, because applicant had met “most of his goals with little improvement in the remaining unmet goals” over the previous two months and because it was “unclear how long this therapy is planned to continue or how the conclusion was reached that he will need long term treatment,” the requested treatment was non-certified.
After an expedited hearing, the Workers’ Compensation Judge (WCJ) issued a September 24, 2024 Findings and Order (F&O) determining that the WCAB had jurisdiction to decide the dispute over medical treatment and that, pursuant to Patterson v. The Oaks Farm 2014 Cal.Wrk.Comp.P.D.LEXIS 98 (significant panel decision), defendant must continue to authorize brain injury treatment at CNS until such time as defendant could demonstrate a material change in applicant’s condition.
On reconsideration, defendant argued that the WCAB lacked jurisdiction because the Utilization Review (UR) decision was timely and that the UR decision itself demonstrated the change in circumstances required under Patterson, insofar as it documented a lack of recent progress resulting from applicant’s ongoing treatment. Defendant also asserted that “by the very nature of the limited duration in the PTP’s request for the day treatment program since its inception, it was never intended that the day treatment program be forever or even ongoing.”
The Appeals Board panel affirmed the WCJ’s F&O noting that, pursuant to Labor Code (LC) section 4600(a), an industrially injured worker is entitled, at their employer’s expense, to medical treatment reasonably required to cure or relieve the effects of the industrial injury. Further, the panel observed that, pursuant to Patterson, an employer may not unilaterally cease to provide treatment authorized as reasonably required to cure or relieve the effects of industrial injury without substantial medical evidence of a change in the employee’s circumstances or condition. The panel agreed with the WCJ that, under Patterson, “the applicant does not have the burden of proving the ongoing reasonableness and necessity of the services…[r]ather, the employer has the burden to show that the continued provision of the services is no longer reasonably required due to a change in the applicant’s condition or circumstances.”
The panel rejected defendant’s argument that the WCAB lacked jurisdiction over the matter because the UR decision was timely. Citing Los Angeles County MTA v. Workers’ Comp. Appeals Bd. (Burton) (2024) 89 Cal.Comp.Cases 977 [2024 Cal. Wrk. Comp. LEXIS 55] (writ denied), the panel concluded that the submission of the April 2024 RFA to UR was invalid absent a precipitating change in circumstance. In Burton, the WCJ noted that “the whole point of Patterson is that a Form RFA is not required in certain circumstances involving care of an ongoing nature…[t]he decision is about when an RFA is required, and if one is not required in the first place, then there can be no valid UR therefrom, timely or otherwise.” The panel agreed with the WCJ that there was no evidence in the record of any change in applicant’s condition or circumstance that would reasonably support the initiation of utilization review to re-evaluate the medical necessity of his treatment. The panel further stated that in “the absence of a change in circumstance, applicant’s previously authorized treatment continues to be medically necessary. Because there is no reasonable basis to assert a dispute regarding the medical necessity of treatment that has already been determined to be reasonable and necessary, the Appeals Board retains its jurisdiction to determine the award of medical treatment. (Lab. Code, § 4604; Dubon II, supra, at p. 1305.)”
As noted, the panel affirmed the WCJ, holding that defendant had not met its “affirmative” burden of establishing a material change in applicant’s medical treatment, circumstance or condition that would otherwise require defendant to either authorize the requested treatment or submit the request through UR. Because there was no valid medical dispute arising from a change of condition, the defendant was obligated to continue to provide treatment at CNS.
By Rachel Fortner, Esq., Associate Attorney, Santa Rosa Office, June 2025
