Medical Treatment (3/3)

  1. De Guevara v. La Golondrina BPD) (2016 Cal. Wrk. Comp. P.D. LEXIS 84):


The evidence established that the applicant called five doctors from the MPN list who did not accept her as a patient. The WCAB ruled that the five phone calls did not meet applicant’s burden of proof that the applicant was denied medical care and therefore entitled to treat outside defendant’s MPN.


The WCAB took note of the fact that there were more and 65 doctors within 15 miles of applicant’s ZIP Code who are qualified to treat her for her condition. The WCAB found that her efforts to contact only five of the doctors did not shift the burden to the defendants to establish that reasonable treatment was available within the MPN.


An additional important issue appeared to be that the applicant did not avail herself of the medical access assistance available pursuant to Labor Code § 4616 (a) (5). The WCAB appeared to have a problem with allowing treatment outside the defendant’s MPN when the applicant did not avail themselves of this service.


  1. Romero v. Stones and Tradition(SCIF) (BPD) (44 CWCR 91):


The WCJ found a UR decision dated September 14, 2015 was timely as to two treatment modalities but was untimely as to oxycodone and H-wave supplies. The WCJ found that the oxycodone and H-wave supplies are reasonable necessary to cure from applicant’s injury.


Defendant filed a petition for reconsideration. The Board stated that Labor Code §4610(g)(1) requires that prospective or concurrent UR decisions shall be made in a timely fashion not to exceed five working days from receipt of the information reasonably necessary to make that determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician.


The Board stated that Labor Code § 4610 (g) (1) provides two alternative timelines within which the Utilization review determination must be made.


AD rule 9792.9 .1 states a request for authorization must be made on a DWC Form RFA. Rule 9792.9 .1 (c) provides that the UR timeframe is extended when additional information is requested necessitating an extension under subdivision (f).


Rule 9792.9 .1 (f) (1) (A) provides that once an RFA is submitted the timeframe for UR decision may be extended if the claims administrator or reviewer is not in receipt of all the information reasonably necessary to make a determination.


In cases where additional information is necessary, a reviewer or non-physician reviewer shall request the information from the treating physician within five business days from receipt of the request for authorization. Once the additional information is requested, if the additional information requested is not received within 14 days from the receipt of the completed request for authorization for prospective or concurrent review the reviewer cell deny the request with the stated condition the request will be considered upon receipt of the information.


Dubon v. World Restoration (Appeals Board en banc) (79 CCC 1298 held that when the UR determination is timely made, Independent Medical Review is the sole mechanism for reviewing the UR physician expert opinion regarding the medical necessity of propose procedure.


The WCJ found the August 12, 2015 UR decision was timely and the WCAB upheld that decision. The WCAB found therefore defendant was not aggrieved by this decision.


The September 14, 2015 UR decision was a perspective review of four different treatment modalities. UR physician requested additional information pertaining to two of the treatment modalities and issued a decision within 14 days as required by Labor Code 4610. The WCJ reason that the UR decision should have issued a decision regarding the two treatment modalities for which no additional information was required within five days.


The WCAB provides that an RFA triggers the timelines for completing utilization review and does not contemplate different timelines for different treatment request within an RFA. Accordingly, the September 14, 2015 UR decision is timely as to all modalities requested five the RFA.


The WCAB reversed found that the applicant was not entitled to treatment denied by the August 12, 2015 utilization review.

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