What the panel ordered
Petition for Reconsideration denied.
Defendant sought reconsideration of the Findings and Orders issued on April 16, 2024, which were recommended for denial by the WCJ's Report and Recommendation on Petition for Reconsideration.
This docket was decided more than once. Shown here is the latest released decision; we also hold June 28, 2022.
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.
The Appeals Board found no legal basis for defendant's claim for reimbursement of payments made for residential treatment because the utilization review determinations were untimely and invalid, and there was no evidence of fraud or unjust enrichment.
From the decision · page 7Although we discern no error in the WCJ's finding that the UR determinations were untimely and, as such, that applicant's medical treatment was not subject to UR, we nevertheless address defendant's contention that the record establishes its entitlement to reimbursement for payments made for residential treatment provided to applicant after it disputed the medical necessity of the treatment. Specifically, defendant argues that after it issued UR determinations denying applicant's requests for continued residential treatment, applicant was required by Labor Code section 4610.5 to seek IMR of the determinations or be bound by them--and that applicant's failure to seek IMR gives rise to a right of reimbursement. (Petition, p. 6:3-7.)
The Appeals Board upheld the WCJ's finding that defendant was barred from discontinuing applicant's residential treatment without agreement from applicant's physician on a safe discharge plan appropriate for his medical needs.
From the decision · page 11Labor Code section 4610(i)(4)(C), as applicable here, provides: In the case of concurrent review, medical care shall not be discontinued until the employee's physician has been notified of the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of the employee. Medical care provided during a concurrent review shall be care that is medically necessary to cure and relieve, and an insurer or self-insured employer shall only be liable for those services determined medically necessary to cure and relieve.
The WCJ found the utilization review (UR) determinations untimely as they were not issued within 72 hours as required for the applicant's serious health condition, and the Appeals Board found no error in this finding.
From the decision · page 6Labor Code section 4610(i) applies to RFAs for treatment, whether made "prior to, retrospectively, or concurrent with the provisions of medical treatment services." (Lab. Code § 4610(i).) Under Labor Code section 4610(i)(3), "If the employee's condition is one in which the employee faces an imminent and serious threat to the employee's health..., or the normal timeframe for the decisionmaking process... would be detrimental to the employee's life or health or could jeopardize the employee's ability to regain maximum function, decisions to approve, modify, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees shall be made in a timely fashion that is appropriate for the nature of the employee's condition, but not to exceed 72 hours after the receipt of the information reasonably necessary to make the determination." (Lab. Code § 4610(i)(3); see also Cal. Code Regs., tit. 8, § 9792.9.1(e)(3).)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Applicant sustained serious injuries including traumatic brain injury, fractures, and cognitive impairments requiring post-acute residential care.
Favours Applicant prevailed
This established the applicant's condition as serious and imminent, triggering the requirement for timely utilization review determinations within 72 hours, which defendant failed to meet.
From the decision · page 4S1 11. Left low back pain 12. Left sided hearing loss worse than the right 13. Left jaw pain 14. Left 3-7th rib fractures (minimally displaced) 15. Right 4th anterlolateral fracture (non-displaced) 16. Double vision & Blurry vision 17. Possible left inferior visual field deficit 18. Horizontal Nystagmus on Leftward gaze 19. Right temporal calvarium and sphenoid wing fractures extend to the right superior lateral orbital wall and right lateral orbital wall. 20. Right-sided LeFort type Ill fracture. 21. Extraconal hematoma and soft tissue air within the right superior lateral orbit measuring 4 mm contrast asymmetric right globe proptosis. 22. Comminuted right zygomatic arch fracture 23. Nasal septal fracture (without nasal septal hematoma) 24. Dyspnea from left nostril secondary to nasal fracture 25. Insomnia 26. Depression/Anxiety/Adjustment Disorder/PTSD 27. Possible Pseudobulbar affect (Ex. 15, Report of Allen Huang, M.D. dated September 30, 2021, pp. 1-2.)
Defendant's utilization review determinations were untimely and materially defective, undermining their integrity and effectiveness.
Favours Applicant prevailed
This invalidated the utilization review determinations, allowing the applicant to continue treatment without being bound by them and negating defendant's claim for reimbursement.
From the decision · page 12As we explained, defendant's UR determinations denying continued residential treatment were untimely and materially defective, rendering them incomplete and ineffective. Lien claimant, in the absence of a legal finding that the determinations were invalid, continued to provide applicant with residential treatment until September 30, 2021, when it requested that the treatment be discontinued in favor of home and community program treatment and home health care on the grounds that continued residential treatment had not been authorized. (Ex. 5, Request for Authorization dated September 30, 2021, p. 1; Ex. 15, Report of Allen Huang, M.D. dated September 30, 2021, pp.
Defendant discontinued applicant's residential treatment without obtaining agreement from applicant's physician on a safe discharge plan.
Favours Applicant prevailed
This violated Labor Code section 4610(i)(4)(C) and Administrative Director's Rule 9792.9.1(e)(6), supporting the applicant's entitlement to continued treatment.
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Reported extensive injuries including traumatic brain injury, fractures, vision and hearing deficits, and psychiatric conditions, supporting the need for post-acute residential care.
The physician's report established the serious nature of applicant's condition relevant to the timeliness requirement for utilization review determinations.
From the decision · page 4S1 11. Left low back pain 12. Left sided hearing loss worse than the right 13. Left jaw pain 14. Left 3-7th rib fractures (minimally displaced) 15. Right 4th anterlolateral fracture (non-displaced) 16. Double vision & Blurry vision 17. Possible left inferior visual field deficit 18. Horizontal Nystagmus on Leftward gaze 19. Right temporal calvarium and sphenoid wing fractures extend to the right superior lateral orbital wall and right lateral orbital wall. 20. Right-sided LeFort type Ill fracture. 21. Extraconal hematoma and soft tissue air within the right superior lateral orbit measuring 4 mm contrast asymmetric right globe proptosis. 22. Comminuted right zygomatic arch fracture 23. Nasal septal fracture (without nasal septal hematoma) 24. Dyspnea from left nostril secondary to nasal fracture 25. Insomnia 26. Depression/Anxiety/Adjustment Disorder/PTSD 27. Possible Pseudobulbar affect (Ex. 15, Report of Allen Huang, M.D. dated September 30, 2021, pp. 1-2.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610(i); Cal. Code Regs., tit. 8, 9792.9.1(e)(3)
Labor Code section 4610(i) and related regulations require timely utilization review decisions for serious health conditions, not exceeding 72 hours after receipt of necessary information.
Applied to determine that defendant's utilization review determinations were untimely for applicant's serious health condition.
From the decision · page 6Labor Code section 4610(i) applies to RFAs for treatment, whether made "prior to, retrospectively, or concurrent with the provisions of medical treatment services." (Lab. Code § 4610(i).) Under Labor Code section 4610(i)(3), "If the employee's condition is one in which the employee faces an imminent and serious threat to the employee's health..., or the normal timeframe for the decisionmaking process... would be detrimental to the employee's life or health or could jeopardize the employee's ability to regain maximum function, decisions to approve, modify, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees shall be made in a timely fashion that is appropriate for the nature of the employee's condition, but not to exceed 72 hours after the receipt of the information reasonably necessary to make the determination." (Lab. Code § 4610(i)(3); see also Cal. Code Regs., tit. 8, § 9792.9.1(e)(3).)
What proof carried it
The evidence the panel weighed, by kind.
Defendant's utilization review determinations were untimely and materially defective, undermining their integrity and effectiveness.
From the decision · page 12As we explained, defendant's UR determinations denying continued residential treatment were untimely and materially defective, rendering them incomplete and ineffective. Lien claimant, in the absence of a legal finding that the determinations were invalid, continued to provide applicant with residential treatment until September 30, 2021, when it requested that the treatment be discontinued in favor of home and community program treatment and home health care on the grounds that continued residential treatment had not been authorized. (Ex. 5, Request for Authorization dated September 30, 2021, p. 1; Ex. 15, Report of Allen Huang, M.D. dated September 30, 2021, pp.
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
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