What the panel ordered
Petition for reconsideration granted; Findings and Order on Appeal of Administrative Director's IMR Determination rescinded; dispute remanded to Administrative Director for submission to a different independent review organization or reviewer.
Applicant sought reconsideration of the Findings and Order on Appeal of Administrative Director's IMR Determination issued on March 22, 2022, challenging the denial of home healthcare 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 IMR determination applied the MTUS guidelines in a plainly erroneous manner based on ordinary knowledge and not expert opinion, failing to properly consider applicant's severe difficulty with activities of daily living and use of assistive device as homebound.
From the decision · page 10For the foregoing reasons, IT IS ORDERED that the Petition for Reconsideration of the Findings and Order on Appeal of Administrative Director's IMR Determination issued on March 22, 2022 is GRANTED. IT IS FURTHER ORDERED, as the Decision After Reconsideration of the Workers' Compensation Appeals Board, that the Findings and Order on Appeal of Administrative Director's IMR Determination issued on March 22, 2022 is RESCINDED, and the following is SUBSTITUTED therefor:
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Applicant has severe difficulty with activities of daily living and ambulates with an assistive device such as a walker.
Favours Applicant prevailed
This fact supports the finding that the applicant is homebound and requires home healthcare, contrary to the IMR determination.
From the decision · page 7Here, the IMR reviewer relied upon MTUS providing that "[h]ome healthcare is selectively recommended... to overcome deficits in activities of daily living... [and indicated when] the patient is unable to leave the home without... [a] walker." (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, pp. 14-15; Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) In doing so, the reviewer explicitly recognized medical evidence that applicant has "' severe difficulty' with activities of daily living" and "ambulates with [an] assistive device" due to those difficulties. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) Yet the reviewer concluded that home healthcare was "not medically necessary" without explaining how this evidence fell outside the MTUS or citing evidence that applicant was able to perform daily living activities without difficulty or ambulate without an assistive device or was not "homebound" as her primary treating physician had opined. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 8; Ex. 1, Dr. Ahmed's June 14, 2021 Report, pp. 2-11.)
The IMR determination improperly relied on lack of documentation of home health evaluation to deny home healthcare.
Favours Applicant prevailed
The Board found this reliance was a plainly erroneous application of MTUS guidelines and supported granting reconsideration.
From the decision · page 7In addition, the IMR reviewer relied upon MTUS providing that a "home evaluation is necessary to develop the home health care treatment plan" as a separate ground supporting the conclusion that home healthcare was not medically necessary. (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15; Ex. 4, IMR Final Determination dated January 12, 2022, p. 8.) However, the MTUS do not state that a home evaluation must be performed in order for home healthcare to be recommended, but rather to ensure that such care is provided safely and correctly. (Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15.) It follows that the IMR reviewer's conclusion that the lack of "documentation of home health evaluation" provided an additional ground to deny applicant's home healthcare request was also based upon a plainly erroneous application of the MTUS.
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.
Applicant is homebound due to severe difficulty with activities of daily living and requires home health care assistance for 4 hours a day, 4 days a week for 3 months.
Dr. Ahmed opined applicant is homebound and needs home health care based on her severe difficulty with activities of daily living and use of assistive device.
From the decision · page 4Question #1. Discussion on activities of daily living: Answer: The patient has severe difficulty with activities of daily living. She is using a walker to assist with ambulation. She cannot do dishes or household chores. She has difficulty with self-care and personal hygiene including bathing and going to the restroom. She has difficulty carrying groceries or pushing grocery carts. She has difficulty with kneeling, squatting, climbing, bending and stooping activities and difficulty climbing stairs. She has difficulty with grasping and lifting. She has difficulty driving the car. The patient cannot stand for prolonged periods of time and therefore, unable to cook or do dishes. Question #2: Please provide opinion as to whether or not there are any other alternatives for treatment that may increase applicant's ability to perform any or all activities of daily living without assistance or supervision. Answer: The patient is status post left knee arthroscopic surgery and status post left knee manipulation under anesthesia done January 22, 2021.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Stevens v. Workers' Comp. Appeals Bd. (2015) 241 Cal.App.4th 1074
IMR determinations are subject to meaningful review and can be set aside if based on plainly erroneous facts not subject to expert opinion.
The Board found the IMR determination applied MTUS guidelines in a plainly erroneous manner based on ordinary knowledge and not expert opinion.
From the decision · page 6plied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review pursuant to section 4610.5 and not a matter that is subject to expert opinion. In upholding a challenge to the Constitutionality of section 4610.6, the Court of Appeal held that IMR determinations are subject to meaningful review, even if the Appeals Board cannot change medical necessity determinations, noting that "[t]he Board's authority to review an IMR determination includes the authority to determine whether it was adopted without authority or based on a plainly erroneous fact that is not a matter of expert opinion." (Stevens v. Workers' Comp. Appeals Bd. (2015) 241 Cal.App.4th 1074, 1100.)
Labor Code section 4610.6(i)
Labor Code section 4610.6(i) requires remand to a different independent review organization or reviewer if IMR determination is reversed.
The Board ordered remand of the dispute to the Administrative Director for submission to a different independent review organization or reviewer.
From the decision · page 8Section 4610.6(i) provides in pertinent part as follows:
What proof carried it
The evidence the panel weighed, by kind.
Lack of documentation of home health evaluation was improperly used to deny home healthcare request.
From the decision · page 7In addition, the IMR reviewer relied upon MTUS providing that a "home evaluation is necessary to develop the home health care treatment plan" as a separate ground supporting the conclusion that home healthcare was not medically necessary. (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15; Ex. 4, IMR Final Determination dated January 12, 2022, p. 8.) However, the MTUS do not state that a home evaluation must be performed in order for home healthcare to be recommended, but rather to ensure that such care is provided safely and correctly. (Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15.) It follows that the IMR reviewer's conclusion that the lack of "documentation of home health evaluation" provided an additional ground to deny applicant's home healthcare request was also based upon a plainly erroneous application of the MTUS.
Applicant's severe difficulty with activities of daily living and use of assistive device such as a walker.
From the decision · page 7Here, the IMR reviewer relied upon MTUS providing that "[h]ome healthcare is selectively recommended... to overcome deficits in activities of daily living... [and indicated when] the patient is unable to leave the home without... [a] walker." (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, pp. 14-15; Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) In doing so, the reviewer explicitly recognized medical evidence that applicant has "' severe difficulty' with activities of daily living" and "ambulates with [an] assistive device" due to those difficulties. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) Yet the reviewer concluded that home healthcare was "not medically necessary" without explaining how this evidence fell outside the MTUS or citing evidence that applicant was able to perform daily living activities without difficulty or ambulate without an assistive device or was not "homebound" as her primary treating physician had opined. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 8; Ex. 1, Dr. Ahmed's June 14, 2021 Report, pp. 2-11.)
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About this page
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