What the panel ordered
The Appeals Board grants the Petition for Reconsideration and defers issuance of a final decision pending further review of the merits and the entire record.
Applicant seeks reconsideration of the Findings of Fact and Order issued by the WCJ on June 27, 2024, which found the UR of the January 25, 2023 treatment request untimely and the treatment not reasonable or necessary. The WCJ's decision was vacated and the matter set for further review.
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 the WCJ erred in deeming the treatment moot due to passage of time, granting reconsideration to further review the merits and evidence of treatment necessity.
From the decision · page 1Applicant seeks reconsideration of the Findings of Fact and Order issued by the workers' compensation administrative law judge (WCJ) in this matter on June 27, 2024. In that decision, the WCJ found in pertinent part that applicant, while employed on June 3, 2021 as a gardener by defendant, sustained industrial injury arising out of and in the course of his employment to the head, neck, and concussion. The WCJ further found that the Utilization Review (UR) of the January 25, 2023 treatment request for authorization (RFA) was untimely, however the treatment requested in the RFA was not reasonable or necessary. Further, that the issue was moot as a new determination could now be obtained under Labor Code section 4610(k)1, and that Patterson2 does not apply to this case at this time.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The UR determination at issue is over a year old and no longer in effect under Labor Code section 4610(k), allowing a new determination to be obtained.
Favours Applicant prevailed
This fact supports that the issue is not moot and treatment entitlement remains.
From the decision · page 5As to the first ground, I agree, the need for treatment is not moot solely based on the passage of time, but UR determinations do. Here, the UR determination at issue is over a year old. As provided under Labor Code § 4610 (k), the UR decision denying the recommended treatment is no longer in effect and a new one can be obtained. Applicant is still very much entitled to medical treatment subject to UR approval.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
If a UR decision is untimely, the determination of medical necessity may be made by the Appeals Board based on substantial evidence.
The Board applied this standard to review the untimely UR decision and treatment necessity.
From the decision · page 6In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298, 1299 (Appeals Board en banc) (Dubon II), the Appeals Board held that if a UR decision is untimely, the UR decision is invalid and not subject to independent medical review (IMR). If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board based on substantial evidence. (Id. at pp. 1300; 1312.)
What proof carried it
The evidence the panel weighed, by kind.
The PTP diagnosed mild traumatic brain injury; IMR noted MTUS recommends home and community-based rehabilitation for traumatic brain injury; treatment sought was a transitional living residential program.
From the decision · page 5Here, the PTP diagnoses the applicant with mild traumatic brain injury (Exhibit 3, page 3). The IMR (Exhibit C, page 3) states that the MTUS recommends home and community based rehabilitation for traumatic brain injury. The treatment being sought in this RFA is for a transition living residential program (see Exhibit U).
The same issues, filtered across the whole corpus — or paste your own facts and let the search rank by factor match.
About this page
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