Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610
Labor Code section 4610 regarding timeliness of utilization review decisions
Applied to determine timeliness of UR decisions and Appeals Board jurisdiction
From the decision · page 6employer. (Lab. Code, § 4610 et seq.) These time limits are mandatory. In Dubon v. World
Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) (Dubon II), the
Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If a UR
decision is untimely, the determination of medical necessity for the treatment requested may be
made by the Appeals Board. (Id. at p. 1300.) If the UR decision is timely, the Appeals Board has
no jurisdiction to address disputes regarding the UR because "[a]ll other disputes regarding a UR
decision must be resolved by IMR." (Id. at p. 1299.)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
Held Appeals Board has jurisdiction to determine timeliness of UR decisions; if timely, medical necessity disputes go to IMR
From the decision · page 6employer. (Lab. Code, § 4610 et seq.) These time limits are mandatory. In Dubon v. World
Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) (Dubon II), the
Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If a UR
decision is untimely, the determination of medical necessity for the treatment requested may be
made by the Appeals Board. (Id. at p. 1300.) If the UR decision is timely, the Appeals Board has
no jurisdiction to address disputes regarding the UR because "[a]ll other disputes regarding a UR
decision must be resolved by IMR." (Id. at p. 1299.)
Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519
Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519 (significant panel decision)
Held that timely made but untimely communicated UR decisions are untimely; applied to communication timeliness
From the decision · page 6Subsequent to Dubon II, in a significant panel decision, the Appeals Board held that a UR
decision that is timely made, but is not timely communicated, is untimely. (Bodam v. San
Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519.)5 In Bodam, the
employer did not notify the requesting physician of its UR decision within 24 hours and did not
send written notice of the UR decision to the physician, applicant or applicant's attorney within
two business days after the UR decision was made. (Id. at p. 1523.)6 The UR decision was
therefore deemed untimely and the Appeals Board had authority to determine the issue of medical
necessity for the disputed treatment.
Labor Code sections 5814 and 5814.5
Labor Code sections 5814 and 5814.5 regarding penalties and attorney's fees for unreasonable delay or refusal of medical treatment
Applied to determine entitlement to penalties and attorney's fees
From the decision · page 11An employee shall not be entitled to an increase in compensation under Section
5814 for unreasonable delay in the provision of medical treatment for periods of
time necessary to complete the utilization review process in compliance
with Section 4610. A determination by the appeals board or a final
determination of the administrative director pursuant to independent medical
review that medical treatment is appropriate shall not be conclusive evidence
that medical treatment was unreasonably delayed or denied for purposes of
penalties under Section 5814. In no case shall this section preclude an employee
from entitlement to an increase in compensation under Section 5814 when an
employer has unreasonably delayed or denied medical treatment due to an
unreasonable delay in completion of the utilization review process set forth
in Section 4610.