Challenging UR Denials
Two recent panel decisions have issued, which although have not been designated as significant, provide another avenue for applicants to challenge Utilization Review denials of medical treatment aside from the objection procedure set forth by Labor Code Section 4062.
The panels in Becerra v. Jack’s Bindery Inc. (2012 Cal. Wrk. Comp. P.D. LEXIS 451) and Corona v. Los Aptos Christian Fellowship Childcare (2012 Cal. Wrk. Comp. P.D. LEXIS 459) both interpreted Labor Code Section 4610(g)(1) to require the employer to provide sufficient medical information to Utilization Review in order to make a determination whether the treatment requested is reasonable and necessary, which may be more than just the report requesting authorization (one decision indicated a full medical background was necessary). Both courts concluded that an applicant may and is entitled to request an Expedited Hearing to litigate the issue of whether the UR denial was timely and properly conducted.
Once the parties reach an Expedited Hearing, the burden is on defendants to provide substantial evidence that proper documentation was provided to UR and that the denial was made and communicated timely to the necessary parties or be found procedurally improper. An Applicant can then provide substantial medical evidence that the treatment requested is necessary and obtain an Order from the WCJ that the treatment be provided.
The Labor Code does mandate that an applicant follow Section 4062 to object to a UR denial, however, the courts have found it appropriate to request an Expedited Hearing simultaneously, allowing applicants that are unsuccessful at the hearing to continue litigating their objection through the QME process (or if successful, cancel it). The same procedure will likely be allowed when IMR (Independent Medical Review) is applicable.
Defendants should be on alert that applicant’s attorneys may start requesting proof of the documentation that is forwarded to Utilization Review along with requests for authorization and, therefore, should be sure to send all medical information that is necessary for the UR physicians to make an informed decision. Failure to follow these recommendations could lead to unnecessary and costly litigation over treatment that may ultimately have to be provided anyway.