Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610(a)
Utilization review (UR) under Labor Code section 4610(a) requires review and approval of treatment recommendations by physicians prior to or concurrent with medical treatment services.
Defendant argued diagnostic testing required UR, but the Board found diagnostic testing is generally a medical-legal expense, not medical treatment, and thus not subject to UR.
From the decision · page 2DISCUSSION
Defendant authorized lien claimant to conduct an examination of applicant. However,
defendant argues that such an examination does not implicitly include diagnostic tests required to
diagnose applicant's condition. Defendant argues that diagnostic testing is subject to utilization
review (UR).
Per Labor Code2 section 4610(a):
For purposes of this section, "utilization review" means utilization review or
utilization management functions that prospectively, retrospectively, or
concurrently review and approve, modify, or deny, based in whole or in part on
medical necessity to cure and relieve, treatment recommendations by
physicians, as defined in Section 3209.3, prior to, retrospectively, or concurrent
with the provision of medical treatment services pursuant to Section 4600.
Labor Code section 4621
Medical-legal expenses are compensable if reasonably, actually, and necessarily incurred under Labor Code section 4621.
The Board found the lien claimant's diagnostic testing and examination reasonable and necessary, thus compensable.
From the decision · page 3Whether a medical-legal expense is compensable depends on whether the expense is
"reasonably, actually, and necessarily incurred". (§ 4621.) While a primary treater may request
authorization for diagnostic testing, such a request is not generally subject to utilization review,
but instead is simply seeking defendant's agreement that the medical-legal expense is reasonable
before it is provided. Here, the primary treater provided medical-legal services in connection with
an examination that defendant expressly authorized. All of the medical-legal services provided
appear reasonable.
Labor Code section 4603.2(b)(2)
Defendant must inform the primary treater of objections to medical-legal services under Labor Code section 4603.2(b)(2).
Defendant failed to provide proper objection to the primary treater regarding the medical-legal services, supporting the Board's affirmation of the lien award.
From the decision · page 3In essence, defendant argues that it authorized an examination with applicant, but that any
specific modality of examination should have been approved by UR. Defendant's argument is not
supported by the law. Defendant was free to challenge the medical-legal services provided at the
consultation as unreasonable, but defendant produced no evidence of this. Furthermore, even if
the medical-legal testing in this case was subject to UR, defendant was free to conduct
retrospective UR to establish whether the services provided were reasonable, but no evidence of
retrospective UR is in the record. Furthermore, defendant was required to inform the primary
treater of its objection, but no proper objection from defendant is in the record pursuant to section
4603.2(b)(2).