ADJ12205629 — California WCAB decision

What the panel ordered

Affirmed the WCJ's Findings of Fact except amended to find applicant entitled to future medical care.

Petition for reconsideration of the April 6, 2023 Findings of Fact by the WCJ, seeking further medical treatment for the industrial injury.

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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.

Medical treatment / UR / IMRApplicant prevailedright ankle

The Appeals Board found that the applicant is entitled to future medical care despite the WCJ's initial conclusion, noting that the appropriate dispute mechanism for treatment necessity is the utilization review process.

From the decision · page 2In this case, we disagree with the WCJ's conclusion that they "[do] not have the power to award a future medical" based on the panel qualified medical evaluator (QME)'s present reporting. (Report and Recommendation p. 3.) Specifically, we note that applicant need not establish that he will certainly need future medical care for an award of future medical care to issue and the appropriate way for a defendant to dispute whether treatment is reasonable and necessary is through the UR process. (See Lab. Code, § 4610.)2

The facts that decided it

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code section 4600

Labor Code section 4600 requires employer to provide reasonable medical treatment to cure or relieve effects of industrial injury.

The Board applied this standard to affirm entitlement to future medical care.

From the decision · page 2Labor Code section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).) An award of medical care "reasonably required to cure or relieve the injured employee of the effects of his or her injury" is not an award of a specific treatment.

Labor Code section 4610

Utilization review (UR) process is the appropriate mechanism to determine reasonableness and necessity of specific treatment requests.

The Board noted that disputes over treatment necessity should be resolved through UR.

From the decision · page 2Whether a specific treatment is reasonable and necessary is typically determined through utilization review (UR). Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.) In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298, 1299 (Appeals Bd. en banc) (Dubon II), the Appeals Board held that if a UR decision is untimely, the UR decision is invalid and not subject to independent medical review (IMR). The Dubon II decision further held that the Appeals Board has jurisdiction to determine whether a UR decision is timely. (Id.) If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) However, "where a UR decision is timely, IMR is the sole vehicle for reviewing the UR physician's expert opinion regarding the medical necessity of a proposed treatment." (Id. at pp. 1310-1311; see also Lab. Code, § 4062(b), 4610.5.)

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Bd. en banc)

If a UR decision is untimely, the Appeals Board has jurisdiction to determine medical necessity; if timely, IMR is the sole review vehicle.

The Board cited this case to explain the jurisdictional limits of UR and IMR in treatment disputes.

From the decision · page 2Whether a specific treatment is reasonable and necessary is typically determined through utilization review (UR). Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.) In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298, 1299 (Appeals Bd. en banc) (Dubon II), the Appeals Board held that if a UR decision is untimely, the UR decision is invalid and not subject to independent medical review (IMR). The Dubon II decision further held that the Appeals Board has jurisdiction to determine whether a UR decision is timely. (Id.) If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) However, "where a UR decision is timely, IMR is the sole vehicle for reviewing the UR physician's expert opinion regarding the medical necessity of a proposed treatment." (Id. at pp. 1310-1311; see also Lab. Code, § 4062(b), 4610.5.)

ADJ12205629 · April 23, 2024

What the panel ordered

What was disputed, and how it came out

The facts that decided it

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What the panel did with the medical opinions

The rules the panel named

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