What the panel ordered
Reconsideration granted, Findings and Order of February 6, 2026 rescinded, and matter returned to WCJ for further proceedings.
Applicant seeks reconsideration of the Findings and Order dated February 6, 2026, which found that a July 31, 2025 Request for Authorization (RFA) did not qualify for expedited review and was timely, thus the court lacked jurisdiction to determine the medical necessity of the requested services.
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 record was insufficient to determine whether there was a change of circumstance warranting the RFA or the lack of a discharge plan, so the matter was remanded for further proceedings.
From the decision · page 7III. Applicant also argues in the Petition that the utilization review process here was not appropriate as there is no change in circumstance to warrant discontinuing ongoing care at all, much less without a discharge plan in place. While this was not raised as a stated issue for trial, both defendant and applicant addressed this issue, to some extent, in their trial briefs. Further, the issues applicant presents are relevant to determining the validity of the RFA itself and the resulting UR determination. Had applicant not raised these issues in his Petition they would be considered waived. (Lab. Code, § 5904 [petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].) Further, a grant of reconsideration has the effect of causing "the whole subject matter [to be] reopened for further consideration and determination" (Great Western Power Co. v. I.A.C.
The Board found that the RFA was not reviewed by a medical professional within the 72-hour timeframe required for expedited review, thus the WCAB has jurisdiction to determine the medical necessity of the treatment.
From the decision · page 6fax of the RFA indicated it was sent at 3:39 p.m. (Exhibit X.) Thus, it is deemed received on July 31, 2025. (Cal. Code Regs., tit. 8 § 9792.9.1(a)(1), amended effective 04/01/2026.) The determination indicates that the vendor did receive the RFA within the 72 hour timeframe, but there is no indication of when it was reviewed, but the decision date is August 6, 2025, well beyond 72 hours. Moreover, there is no notation in the determination as to the reasons the request did not qualify for expedited review, by the medical professional. While the request is for a program beginning after the typical five day timeframe for decisions pursuant to former AD Rule 9792.9.1 (c)(3), the request still had to be reviewed by a medical professional to determine whether the typical timeframe is not warranted. Moreover, the language in former AD Rule 9792.9.1(c) is disjunctive. Even if the analysis does not satisfy one condition, here the standard timeline component, the rule still requires determining whether there is an imminent threat to the health of the patient. The evidence in the record is not clear that the RFA was reviewed by a medical professional within 72 hours for either reason. If it is untimely, the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The RFA dated July 31, 2025 was received by defendant on July 31, 2025 at 3:39 p.m.
Favours Applicant prevailed
Establishes the start of the 72-hour timeframe for expedited review.
From the decision · page 2The RFA dated July 31, 2025 was sent and received via facsimile by Defendant on July 31, 2025 at approximately 3:39 p.m. (Minutes of Hearing ("MOH"), Stipulation 6 at 2:14-15.)
There is no indication that the RFA was reviewed by a medical professional within 72 hours as required for expedited review.
Favours Applicant prevailed
Supports the Board's finding that the expedited review was not properly conducted, giving the Board jurisdiction.
From the decision · page 6fax of the RFA indicated it was sent at 3:39 p.m. (Exhibit X.) Thus, it is deemed received on July 31, 2025. (Cal. Code Regs., tit. 8 § 9792.9.1(a)(1), amended effective 04/01/2026.) The determination indicates that the vendor did receive the RFA within the 72 hour timeframe, but there is no indication of when it was reviewed, but the decision date is August 6, 2025, well beyond 72 hours. Moreover, there is no notation in the determination as to the reasons the request did not qualify for expedited review, by the medical professional. While the request is for a program beginning after the typical five day timeframe for decisions pursuant to former AD Rule 9792.9.1 (c)(3), the request still had to be reviewed by a medical professional to determine whether the typical timeframe is not warranted. Moreover, the language in former AD Rule 9792.9.1(c) is disjunctive. Even if the analysis does not satisfy one condition, here the standard timeline component, the rule still requires determining whether there is an imminent threat to the health of the patient. The evidence in the record is not clear that the RFA was reviewed by a medical professional within 72 hours for either reason. If it is untimely, the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].)
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.
Requested continuation of Casa Colina Transitional Living Center Interdisciplinary Post Acute Residential Rehab program with 4-6 hours of therapy per day from August 12, 2025 through September 12, 2025 with interpreter and transportation to/from medical appointments.
From the decision · page 2On July 31, 2025, multiple medical professionals from Casa Colina, including Dr. David Patterson issued 16 pages of medical reports and notes relating to services provided and evaluations/progress notes between July 18, 2025 and July 31, 2025 which included various treatment and service recommendations. The report was accompanied by a corresponding Request for Authorization ("RFA") which was faxed to Defendant on July 31, 2025. (Joint Exhibit Z.) The requested treatment at issue is Dr. Patterson's request to "Continue Casa Colina Transitional Living Center Interdisciplinary Post Acute Residential Rehab program with 4-6hrs of therapy/day for the period of [August 12, 2025 through September 12, 2025] w/ interpreter and transportation to/from MD appts." (Id., at 3.) The boxes for "New Request", "Resubmission Change in Material Facts", and "Expedited Review" were all checked. (Id.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Cal. Code Regs., tit. 8, 9792.9.1(c)(4)
Request for Authorization (RFA) must be reviewed by a medical professional within 72 hours for expedited review under AD Rule 9792.9.1(c)(4).
The Board found the RFA was not reviewed by a medical professional within the required timeframe, thus jurisdiction was proper.
From the decision · page 6fax of the RFA indicated it was sent at 3:39 p.m. (Exhibit X.) Thus, it is deemed received on July 31, 2025. (Cal. Code Regs., tit. 8 § 9792.9.1(a)(1), amended effective 04/01/2026.) The determination indicates that the vendor did receive the RFA within the 72 hour timeframe, but there is no indication of when it was reviewed, but the decision date is August 6, 2025, well beyond 72 hours. Moreover, there is no notation in the determination as to the reasons the request did not qualify for expedited review, by the medical professional. While the request is for a program beginning after the typical five day timeframe for decisions pursuant to former AD Rule 9792.9.1 (c)(3), the request still had to be reviewed by a medical professional to determine whether the typical timeframe is not warranted. Moreover, the language in former AD Rule 9792.9.1(c) is disjunctive. Even if the analysis does not satisfy one condition, here the standard timeline component, the rule still requires determining whether there is an imminent threat to the health of the patient. The evidence in the record is not clear that the RFA was reviewed by a medical professional within 72 hours for either reason. If it is untimely, the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].)
Labor Code section 4610.5
Labor Code section 4610.5 governs expedited review of medical treatment requests.
The Board applied this statute to determine the timeliness and jurisdiction of the expedited review.
From the decision · page 1Applicant contends that defendant did not meet their burden of proof that they complied with the timeframes required for expedited review of an RFA pursuant to Labor Code section 4610.5.0F1 Applicant also contends that there was not a change of circumstance warranting the RFA for recertification and that not providing a safe discharge plan is contrary to the Labor Code.
Lab. Code, 5803
The Appeals Board has continuing jurisdiction to rescind, alter, or amend any order, decision, or award for good cause.
The Board exercised continuing jurisdiction to grant reconsideration and remand for further proceedings.
From the decision · page 7(1958) 50 Cal.2d 360, 364.) ["[t]here is no provision in chapter 7, dealing with proceedings for reconsideration and judicial review, limiting the time within which the commission may make its decision on reconsideration, and in the absence of a statutory authority limitation none will be implied."]; see generally Lab. Code, § 5803 ["The appeals board has continuing jurisdiction over all its orders, decisions, and awards.... At any time, upon notice and after an opportunity to be heard is given to the parties in interest, the appeals board may rescind, alter, or amend any order, decision, or award, good cause appearing therefor."].) A decision "must be based on admitted evidence in the record" (Hamilton, supra, at p. 478), and must be supported by substantial evidence. (Lab. Code, § 5903, 5952(d); Lamb v. Workmen's Comp. Appeals Bd. (1974) 11 Cal.3d 274 [39 Cal.Comp.Cases 310]; Garza v. Workmen's Comp. Appeals Bd.
What proof carried it
The evidence the panel weighed, by kind.
No indication that the RFA was reviewed by a medical professional within 72 hours as required for expedited review.
From the decision · page 6fax of the RFA indicated it was sent at 3:39 p.m. (Exhibit X.) Thus, it is deemed received on July 31, 2025. (Cal. Code Regs., tit. 8 § 9792.9.1(a)(1), amended effective 04/01/2026.) The determination indicates that the vendor did receive the RFA within the 72 hour timeframe, but there is no indication of when it was reviewed, but the decision date is August 6, 2025, well beyond 72 hours. Moreover, there is no notation in the determination as to the reasons the request did not qualify for expedited review, by the medical professional. While the request is for a program beginning after the typical five day timeframe for decisions pursuant to former AD Rule 9792.9.1 (c)(3), the request still had to be reviewed by a medical professional to determine whether the typical timeframe is not warranted. Moreover, the language in former AD Rule 9792.9.1(c) is disjunctive. Even if the analysis does not satisfy one condition, here the standard timeline component, the rule still requires determining whether there is an imminent threat to the health of the patient. The evidence in the record is not clear that the RFA was reviewed by a medical professional within 72 hours for either reason. If it is untimely, the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].)
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