What the panel ordered
The WCAB rescinded the February 7, 2022 Findings and Award and substituted new findings denying the September 13, 2021 Request for Authorization and finding no requirement for utilization review; applicant is not entitled to the Functional Restoration Program at defendant's expense.
Defendant sought reconsideration of the WCJ's Findings and Award issued February 7, 2022, which granted applicant's request for Functional Restoration Program treatment authorization; the WCAB granted reconsideration and issued a new decision after reconsideration.
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 September 13, 2021 report from Dr. Small did not document a change in material facts to support the RFA; therefore, utilization review was not required and the applicant is not entitled to the Functional Restoration Program at defendant's expense.
From the decision · page 4Otherwise stated, defendant was not required to submit the September 13, 2021 RFA for UR, and the record does not contain substantial evidence that supports the award of future medical treatment in the form of the Functional Restoration Program requested by Dr. Small. Accordingly, we rescind the F&A and substitute a new Findings of Fact, finding that the September 13, 2021 report from Dr. Small does not constitute substantial evidence in support his September 13, 2021 RFA; that Utilization Review of the September 13, 2021 RFA was not required; and that applicant is not entitled to undergo the Functional Restoration Program at defendant's expense.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The September 13, 2021 report from Dr. Small did not document a change of material facts supporting the RFA.
Favours Defendant prevailed
Without a documented change in material facts, utilization review was not required and the Functional Restoration Program authorization was denied.
From the decision · page 4Otherwise stated, defendant was not required to submit the September 13, 2021 RFA for UR, and the record does not contain substantial evidence that supports the award of future medical treatment in the form of the Functional Restoration Program requested by Dr. Small. Accordingly, we rescind the F&A and substitute a new Findings of Fact, finding that the September 13, 2021 report from Dr. Small does not constitute substantial evidence in support his September 13, 2021 RFA; that Utilization Review of the September 13, 2021 RFA was not required; and that applicant is not entitled to undergo the Functional Restoration Program at defendant's expense.
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.
Dr. Small submitted a September 13, 2021 Evaluation Report and RFA for a Functional Restoration Program, claiming a change in material facts to support the RFA, which was disputed by the WCAB as not documenting such a change.
The WCAB found Dr. Small's September 13, 2021 report did not constitute substantial evidence supporting the RFA and did not document a change in material facts.
From the decision · page 4Otherwise stated, defendant was not required to submit the September 13, 2021 RFA for UR, and the record does not contain substantial evidence that supports the award of future medical treatment in the form of the Functional Restoration Program requested by Dr. Small. Accordingly, we rescind the F&A and substitute a new Findings of Fact, finding that the September 13, 2021 report from Dr. Small does not constitute substantial evidence in support his September 13, 2021 RFA; that Utilization Review of the September 13, 2021 RFA was not required; and that applicant is not entitled to undergo the Functional Restoration Program at defendant's expense.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610(k)
A utilization review decision to modify or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to a further recommendation by the same physician, or another physician within the requesting physician's practice group, for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision.
The WCAB applied this standard to determine that the September 13, 2021 RFA did not show a change in material facts and thus did not require utilization review.
Administrative Director Rule 9792.9.1(h)
A utilization review decision to modify, delay, or deny a request for authorization of medical treatment shall remain effective for 12 months from the date of the decision without further action by the claims administrator with regard to any further recommendation by the same physician for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision.
The WCAB applied this regulation consistent with Labor Code section 4610(k) to conclude the September 13, 2021 RFA did not warrant further action by the employer or claims administrator.
From the decision · page 3Consistent with the provisions of Labor Code section 4610(k), Administrative Director Rule 9792.9.1(h) states:
What proof carried it
The evidence the panel weighed, by kind.
Dr. Small's September 13, 2021 report did not document a change in material facts to support the RFA.
From the decision · page 4Otherwise stated, defendant was not required to submit the September 13, 2021 RFA for UR, and the record does not contain substantial evidence that supports the award of future medical treatment in the form of the Functional Restoration Program requested by Dr. Small. Accordingly, we rescind the F&A and substitute a new Findings of Fact, finding that the September 13, 2021 report from Dr. Small does not constitute substantial evidence in support his September 13, 2021 RFA; that Utilization Review of the September 13, 2021 RFA was not required; and that applicant is not entitled to undergo the Functional Restoration Program at defendant's expense.
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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.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
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