What the panel treated as outcome-determinative, and which side it favoured.
Defendant did not issue a Utilization Review determination within 72 hours of the expedited RFA submitted on February 16, 2024.
Favours Applicant prevailed
This failure rendered the UR determination untimely and triggered the statutory protections for expedited review.
From the decision · page 1Defendant Travelers Property Casualty Company of America seeks reconsideration of the
April 3, 2024 Findings and Award, wherein the workers' compensation administrative law judge
(WCJ) found that treating physician Dr. Shamie submitted a Request for Authorization (RFA) on
February 16, 2024, that the RFA indicated the need for expedited review, and that defendant did
not issue a determination in response to the RFA within 72 hours. The WCJ determined that
defendant's Utilization Review (UR) determination issued on February 21, 2024 was untimely,
and that the request for home caregiver assistance was medically necessary.
No evidence showed that a medical professional reviewed the RFA within the required 72-hour timeframe.
Favours Applicant prevailed
Without such medical review, the defendant's after-the-fact denial of expedited review was invalid.
From the decision · page 2On April 3, 2024, the WCJ issued his determination finding that defendant failed to issue
its UR determination within 72 hours of the February 16, 2024 RFA, rendering defendant's
February 21, 2024 determination untimely. (Finding of Fact Nos. 1 & 2.) The WCJ further
determined the underlying request to be medically necessary and awarded the requested home
health care and medical transportation. (Finding of Fact No. 4; Award, No. "a".) The Opinion
observed that there was no evidence that a medical professional reviewed the RFA marked for
expedited review within 72 hours of receipt. (Opinion on Decision, at pp. 4-5.)
Applicant requires extensive assistance with activities of daily living, consistent with medical treatment guidelines.
Favours Applicant prevailed
Supports the medical necessity of the requested increase in home caregiver services.
From the decision · page 7"integral", and "vital", providing support for eating, bathing, dressing, and
medication management. Accepting as true that applicant requires "extensive"
assistance with bathing, dressing, grooming, transportation, meal preparation,
and medication management, and that her husband is currently providing her
this "essential care and support", it would appear that authorization of such
services would overcome the applicant's deficits in [Activities of Daily Living]
and allow her to avoid inpatient care. A person who, without assistance, cannot
bathe, dress, prepare their own meals, manage their own medications, or
transport themselves outside of the home, is undoubtedly incapable of
independent living. That applicant's husband currently happens to be providing
these services without compensation has no bearing on whether those services
are medically necessary or would otherwise be required to be provided by a 3rd
party at defendant's expense. The Court found and finds that Dr. Shamie's
request is consistent with the treatment
recommendations outlined in the MTUS. Accordingly, the requested home
healthcare services are medically necessary.