What the panel ordered
Petition for Reconsideration granted; final decision deferred pending further review of merits and entire record.
Applicant seeks reconsideration of the May 5, 2025 Findings of Fact by the WCJ, which denied authorization for a functional restoration program and found no jurisdiction to determine medical necessity. The WCAB granted reconsideration and deferred final decision pending further review.
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 WCJ found no jurisdiction to determine medical necessity because the February 24, 2025 RFA did not document a change of material facts to require utilization review. The WCAB granted reconsideration to further review this jurisdictional issue.
From the decision · page 1Applicant seeks reconsideration of the May 5, 2025 Findings of Fact, wherein the workers' compensation administrative law judge (WCJ) found, as stipulated by the parties, that applicant sustained a specific injury of August 12, 2021 to the bilateral wrists, bilateral shoulders, neck, bilateral elbows arising out of and in the course of employment by permissibly self-insured employer United Continental Holdings as a customer service representative. The WCJ also found that the February 24, 2025 report of primary treating physician (PTP) Timothy Lo, M.D., did not document a change of material facts and does not constitute substantial evidence in support of his February 24, 2025 Request for Authorization (RFA) of a functional restoration program. The WCJ further found that Utilization Review (UR) of Dr. Lo's February 24, 2025 RFA was not required, and that the WCAB has no jurisdiction to determine the medical necessity of the functional restoration program requested in that RFA.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The February 24, 2025 report of Dr. Lo did not document a change of material facts to support the new RFA.
Favours Defendant prevailed
Without a documented change of material facts, the WCJ found no jurisdiction to require utilization review or determine medical necessity, leading to denial of the RFA.
From the decision · page 53. The February 24, 2025 report of Timothy Lo, M.D. did not document a change of material facts and does not constitute substantial evidence in support of his February 24, 2025 Request for Authorization.
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. Lo requested authorization for an 80-hour functional restoration program initially in November 27, 2024, and again on February 24, 2025, claiming a change of material facts. The WCJ found the February 24, 2025 report did not document a change of material facts and did not constitute substantial evidence to support the request.
The February 24, 2025 report did not document a change of material facts to support the new RFA, so the WCJ found no jurisdiction to determine medical necessity.
From the decision · page 1Applicant seeks reconsideration of the May 5, 2025 Findings of Fact, wherein the workers' compensation administrative law judge (WCJ) found, as stipulated by the parties, that applicant sustained a specific injury of August 12, 2021 to the bilateral wrists, bilateral shoulders, neck, bilateral elbows arising out of and in the course of employment by permissibly self-insured employer United Continental Holdings as a customer service representative. The WCJ also found that the February 24, 2025 report of primary treating physician (PTP) Timothy Lo, M.D., did not document a change of material facts and does not constitute substantial evidence in support of his February 24, 2025 Request for Authorization (RFA) of a functional restoration program. The WCJ further found that Utilization Review (UR) of Dr. Lo's February 24, 2025 RFA was not required, and that the WCAB has no jurisdiction to determine the medical necessity of the functional restoration program requested in that RFA.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610
Labor Code section 4610 governs utilization review timelines and requirements for medical treatment requests.
The WCJ applied section 4610 to find that the February 24, 2025 RFA did not require utilization review due to lack of documented change in material facts.
From the decision · page 6Utilization Review ("UR") is used to "approve, modify, or deny, in whole or in part" treatment recommendations made by the treating physicians. (Labor Code section 4610(a).) A decision to approve, modify or deny prospective treatment requests are to be made within 5 business days from the receipt of the request for authorization ("RFA.") (Labor Code section 4610(i)(1).) In the absence of a timely UR decision, the WCAB has jurisdiction to determine if the medical treatment requested on the RFA is reasonable and necessary. (Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp. Cases 1298 (Dubon II).)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 clarifies that untimely UR decisions allow WCAB to determine medical necessity, but timely UR decisions must be resolved by IMR.
The WCJ applied Dubon II to conclude that the February 24, 2025 RFA did not require UR and the WCAB lacked jurisdiction to determine medical necessity without a timely UR denial.
From the decision · page 8Also, recognized in the Opinion on Decision is the Appeals Board's en banc decision in Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131] (Dubon II), which held that:
What proof carried it
The evidence the panel weighed, by kind.
The February 24, 2025 report of Dr. Lo did not document a change of material facts to support the new RFA.
From the decision · page 53. The February 24, 2025 report of Timothy Lo, M.D. did not document a change of material facts and does not constitute substantial evidence in support of his February 24, 2025 Request for Authorization.
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About this page
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