What the panel ordered
Defendant's Petition for Reconsideration is denied.
Defendant filed a Petition for Reconsideration of the WCJ's Findings and Award/Opinion on Decision issued January 14, 2024, which found defendant had to comply with their own UR authorization.
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.
A timely Utilization Review approved the requested home relocation, and the court has no jurisdiction to disturb a timely UR approval. Defendant cannot disavow its own UR approval and must comply with it.
From the decision · page 4The court issued a Findings & Award/Opinion on Decision on January 14, 2024, which was served January 18, 2024. It was found that Defendant had to comply with their own UR authorization.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant's Utilization Review provider issued a timely certification approving the treating doctor's Request for Authorization for home relocation.
Favours Applicant prevailed
A timely UR approval means the court has no jurisdiction to disturb the approval, and defendant must comply with it.
From the decision · page 7Defendant submitted the RFA to UR. UR determined that the request was medically necessary given the totality of all the information (applicant as an upper extremity amputee, with psychological trauma from a catastrophic injury who currently lives in a house that cannot be modified to accommodate his injuries). UR consulted the schedule for medical treatment utilization, found that there was no specific MTUS/ACOEM guideline. However, as it was not specifically in the guidelines, the reviewer did proceed to review peer-reviewed literature and determined the request to be appropriate. Jt. Exhibit 2, p. 7. UR then approved the request.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Dubon v. World Restoration (2014) 79 Cal. Comp. Cases 1298 (en banc); King v. CompPartners, Inc. (2018) 5 Cal. 5th 1039
Where a UR decision is timely, IMR is the sole vehicle for reviewing the UR physician's expert opinion regarding the medical necessity of a proposed treatment. The court has no jurisdiction to disturb a timely UR approval.
Applied to hold that the court cannot disturb a timely UR approval and defendant must comply with it.
From the decision · page 5Where a UR decision is timely, IMR is the sole vehicle for reviewing the UR physician's expert opinion regarding the medical necessity of a proposed treatment." Dubon supra, at pp. 1310§ 1311. IMR "is the exclusive mechanism for review of a utilization review decision." King v. CompPartners, Inc. (2018) 5 Cal. 5th 1039, 1048.
What proof carried it
The evidence the panel weighed, by kind.
Timely Utilization Review approval of the treating doctor's Request for Authorization for home relocation, based on applicant's amputation and psychological trauma.
From the decision · page 7Defendant submitted the RFA to UR. UR determined that the request was medically necessary given the totality of all the information (applicant as an upper extremity amputee, with psychological trauma from a catastrophic injury who currently lives in a house that cannot be modified to accommodate his injuries). UR consulted the schedule for medical treatment utilization, found that there was no specific MTUS/ACOEM guideline. However, as it was not specifically in the guidelines, the reviewer did proceed to review peer-reviewed literature and determined the request to be appropriate. Jt. Exhibit 2, p. 7. UR then approved the request.
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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.
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