ADJ15211632 · June 25, 2026

The Appeals Board found that the WCJ erred in concluding the prior UR decision barred the subsequent request and that the December 8, 2025 UR decision was untimely but the requested treatment was medically necessary, warranting reconsideration.

From the decision · page 1Applicant seeks reconsideration of the April 14, 2026 Findings and Order (F&O), wherein the workers' compensation administrative law judge (WCJ) found that a prior utilization review (UR) decision denying authorization for a requested treatment barred a subsequent request for authorization (RFA) for the same treatment submitted on December 4, 2025. The WCJ further determined that the UR decision issued on December 8, 2025 regarding authorization for a wheelchair accessible hotel room was untimely but that the requested services were not medically necessary.

The WCJ found the February 17, 2025 and December 4, 2025 RFAs requested essentially the same treatment and no material change in facts or circumstances was shown to warrant a new UR.

Favours Defendant prevailed

This finding supported the WCJ's denial of the subsequent RFA based on the prior UR bar, which the Board reconsidered.

From the decision · page 7The WCJ's Report asserts that the gravamen of the February 10, 2025 and December 4, 2025 RFAs are essentially the same, and that a change in the terminology used by the treating physician does not fundamentally alter the nature of the underlying request. (Report, at pp. 4-5.) The WCJ also identified no material change in the facts or circumstances material to the February 17, 2025 UR decision, concluding that "[i]nstead of documenting a change in condition material to the utilization review decision, the evidence cited by applicant documents that his condition remains essentially the same and therefore the evidence does not satisfy the exception set forth in Labor Code section 4610(k)." (Id. at p. 10.) Finally, the WCJ's report contends that reporting of Dr. Schweller is conclusory and internally inconsistent and does not establish the medical necessity of the requested treatment. (Id. at p. 13-14.)

The December 8, 2025 UR decision was untimely but the requested wheelchair accessible hotel room treatment was found medically necessary by the applicant's physician.

Favours Applicant prevailed

This supported the Board's grant of reconsideration to further review the merits of medical necessity despite the untimely UR decision.

From the decision · page 1Applicant seeks reconsideration of the April 14, 2026 Findings and Order (F&O), wherein the workers' compensation administrative law judge (WCJ) found that a prior utilization review (UR) decision denying authorization for a requested treatment barred a subsequent request for authorization (RFA) for the same treatment submitted on December 4, 2025. The WCJ further determined that the UR decision issued on December 8, 2025 regarding authorization for a wheelchair accessible hotel room was untimely but that the requested services were not medically necessary.

Requested authorization for multiple treatments including wheelchair accessible van and hotel room accommodation, asserting medical necessity based on patient's condition and injury history.

Denied authorization for requested treatments including wheelchair accessible van and hotel room accommodation, citing lack of updated physical examination findings and medical necessity.

From the decision · page 6On December 8, 2025, UR physician Andrew Nava, M.D., non-certified the entirety of the medical treatment requested by Dr. Schweller, including ongoing home healthcare support, nursing services twice per day, a wheelchair accessible van, and wheelchair accessible hotel room accommodation for 120 days. (Ex. 4, Utilization Review Determination, dated December 8, 2025.) The reviewer noted that "there are no updated physical examination findings documented by the requesting AP to support said request as the last visit was on 11/17/25 and was via telemedicine." (Id. at p. 9.)

Labor Code sections 4610, 4610.5

Utilization Review (UR) and Independent Medical Review (IMR) processes evaluate medical necessity of treatment requests under strict time limits per Labor Code sections 4610 and 4610.5.

The Board reviewed the timeliness and medical necessity of the UR decisions and the applicability of the UR bar to subsequent RFAs.

From the decision · page 9We further observe that under the auspices of California's workers' compensation system, questions relating to the medical necessity of a treatment requested by a physician are decided through compulsory UR and IMR processes. Section 4610 requires that employers establish a UR process. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 241 ("Sandhagen").) Once a treating physician submits an RFA to an employer, the employer must either approve the treatment request or dispute the treatment request and submit the matter for review. When an employer chooses to challenge a treatment request, a UR physician will evaluate whether the requested treatment is "medically necessary," and will either: (1) approve; (2) modify; or (3) deny the requested medical treatment. (Lab. Code, § 4610, subds. (a), (c), (e) & (g)(4).) UR must be accomplished within strict time limits. (Id.; see Dubon v. World Restoration ("Dubon") (2014) 79 Cal.Comp.Cases 1298, 1306 (Appeals Board en banc).)

Labor Code section 5909

Petition for Reconsideration must be acted upon within 60 days of case transmission to the Appeals Board per amended Labor Code section 5909.

The Board found the Petition for Reconsideration was timely served and acted upon within the statutory period.

From the decision · page 2Former section 5909 provided that a petition for reconsideration was deemed denied unless the Appeals Board acted on the petition within 60 days from the date of filing. (Lab. Code, § 5909.) Effective July 2, 2024, section 5909 was amended to state in relevant part that:

The WCJ found no material change in facts or circumstances between the February 17, 2025 and December 4, 2025 RFAs, concluding the evidence showed the condition remained essentially the same.

From the decision · page 7The WCJ's Report asserts that the gravamen of the February 10, 2025 and December 4, 2025 RFAs are essentially the same, and that a change in the terminology used by the treating physician does not fundamentally alter the nature of the underlying request. (Report, at pp. 4-5.) The WCJ also identified no material change in the facts or circumstances material to the February 17, 2025 UR decision, concluding that "[i]nstead of documenting a change in condition material to the utilization review decision, the evidence cited by applicant documents that his condition remains essentially the same and therefore the evidence does not satisfy the exception set forth in Labor Code section 4610(k)." (Id. at p. 10.) Finally, the WCJ's report contends that reporting of Dr. Schweller is conclusory and internally inconsistent and does not establish the medical necessity of the requested treatment. (Id. at p. 13-14.)