ADJ11862779 — California WCAB decision

What the panel ordered

The WCAB affirms the WCJ's Findings of Fact, Award, Order and Opinion on Decision issued February 13, 2020, denying the requested right knee surgery treatment as not established medically necessary.

Applicant seeks reconsideration of the Findings of Fact, Award, Order and Opinion on Decision (F&O) issued by the WCJ on February 13, 2020, which found defendant's utilization review (UR) decision untimely and that applicant did not establish medical necessity for requested treatment.

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What was disputed, and how it came out

Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.

Medical treatment / UR / IMRDefendant prevailedright knee

The UR decision was untimely as it was not served on applicant's attorney within the required time, rendering it invalid. The applicant failed to prove by substantial evidence that the requested knee surgery was medically necessary under the MTUS guidelines or otherwise, so the WCJ's denial of treatment was affirmed.

From the decision · page 4The parties stipulated that the November 22, 2019 UR decision was not served on

The facts that decided it

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code section 4600

Labor Code section 4600 requires employer to provide reasonable medical treatment to cure or relieve effects of industrial injury

Applied to determine employer's obligation for medical treatment

From the decision · page 3Labor Code section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).)1 Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.)

Labor Code section 4610

Labor Code section 4610 requires establishment of utilization review process for treatment requests

Applied to assess UR process and timeliness

From the decision · page 3Labor Code section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).)1 Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.)

Labor Code section 4610(i)(4)(A)-(B)

Labor Code section 4610(i)(4)(A)-(B) requires timely communication of UR decisions to physician, employee, and attorney

Applied to determine timeliness of UR decision communication

From the decision · page 3At the time of the November 22, 2019 UR decision, former section 4610(i) provided as follows for communication of UR decisions as relevant herein:

Administrative Director Rule 9792.9.1(e)(3)

Administrative Director Rule 9792.9.1(e)(3) requires communication of UR decisions within specified timeframes to physician, injured worker, and attorney

Applied to assess compliance with UR decision communication requirements

From the decision · page 3Administrative Director (AD) Rule 9792.9.1 further provides in pertinent part:

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) holds that untimely UR decisions are invalid and not subject to IMR; Appeals Board has jurisdiction to determine medical necessity if UR decision is untimely

Applied to determine invalidity of untimely UR decision and Appeals Board jurisdiction

From the decision · page 4In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298, 1299 (Appeals

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 holds that failure to timely notify physician, applicant, and attorney renders UR decision untimely and invalid

Applied to confirm untimeliness of UR decision due to lack of timely notification

From the decision · page 4Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519.)2 In Bodam, the

ADJ11862779 · March 15, 2021

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