Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4600
Employers are required to provide reasonable medical treatment to cure or relieve the effects of an industrial injury.
Applies to the requirement for medical treatment including home health care services.
From the decision · page 6Employers are required to provide reasonable medical treatment to cure or relieve from the
effects of an industrial injury. (Lab. Code, § 4600.) For home health care services, the Labor Code
provides:
Labor Code section 4600(h)
Home health care services shall be provided as medical treatment only if reasonably required to cure or relieve the injured employee from the effects of the injury and prescribed by a licensed physician.
Defines the conditions under which home health care services are compensable medical treatment.
From the decision · page 6Home health care services shall be provided as medical treatment only if reasonably
required to cure or relieve the injured employee from the effects of the employee's
injury and prescribed by a physician and surgeon licensed pursuant to Chapter 5
(commencing with Section 2000) of Division 2 of the Business and Professions
Code, and subject to Section 5307.1 or 5307.8. The employer is not liable for home
health care services that are provided more than 14 days prior to the date of the
employer's receipt of the physician's prescription.
Labor Code section 4610
Employers are required to conduct utilization review of treatment requests received from physicians.
Mandates utilization review process for medical treatment requests.
From the decision · page 6(§ 4600(h).)
Employers are required to conduct UR of treatment requests received from physicians.
Labor Code section 4610.5
Any dispute over a utilization review decision shall be resolved only by Independent Medical Review (IMR).
Establishes IMR as the exclusive dispute resolution for UR decisions.
From the decision · page 6(Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008)
44 Cal.4th 230, 236.) Section 4610.5 makes IMR applicable to "any dispute over a utilization
review decision," and requires that any such dispute, "shall be resolved only" by IMR. The Medical
Unit reviews UR plans and the IMR programs used to resolve disputes about medical treatment
and medical legal billing. The AD, although not a party to this action, is charged with oversight of
Medical Unit programs that provide care to injured workers.
Labor Code section 4610.6(h)
The Appeals Board may review an IMR determination, which is presumed correct and can only be set aside by clear and convincing evidence of specified grounds including fraud, bias, or plainly erroneous findings of fact.
Sets the standard for Appeals Board review of IMR determinations.
From the decision · page 6Section 4610.6(h) authorizes the Appeals Board to review an IMR determination of the
AD. The section explicitly provides that the AD's determination is presumed to be correct and can
only be set aside by clear and convincing evidence of one or more of the following: (1) The AD
acted without or in excess of the AD's powers; (2) The determination of the AD was procured by
fraud; (3) The IMR reviewer was subject to a material conflict of interest that is in violation of
section 139.5; (4) the determination was the result of bias on the basis of race, national origin,
ethnic group identification, religion, age, sex, sexual orientation, color, or disability; or (5) the
determination was the result of a plainly erroneous express or implied finding of fact, provided
that the mistake of fact is a matter of ordinary knowledge based on the information submitted for
review pursuant to section 4610.5 and not a matter that is subject to expert opinion. Section 4610.6,
subdivision (i) provides: "In no event shall a workers' compensation administrative law judge, the
appeals board, or any higher court make a determination of medical necessity contrary to the
determination of the independent medical review organization."