Labor Code Section 4610 outlines the timeframes in which responses to treatment requests are due. Generally, requests for authorization of treatment are allowed a response with 5 business days or within 14 days upon the timely request for additional information for the treatment being requested. For issues involving an imminent or serious threat to life, these decisions must be addressed within 72 hours of the request made. Two recent panel decisions have addressed this subject matter. Please note these panel decisions have not been marked as significant and are not binding precedents but give guidance to the court’s assessment of the subject.

In Silvia Correa v. Display Products (2024) 89 Cal.Comp.Cases 1075, the issue was addressed as to who can decide whether a request for treatment involves the imminent or serious threat to life requiring a 72-hour response. In this case, the primary treating physician submitted a request for caregiver assistance, 12 hours per day, seven days a week for six months. The defendant had previously provided care at 4 hours per day under a prior stipulated agreement that was set to expire. The RFA itself did come to the claim’s examiner marked as needing an expedited response. The carrier provided their response within the general 5-day time frame indicating the request itself did not establish the need for review with the expedited time frame required. 

If a request is not reasonably supported by evidence establishing that the injured worker faces an imminent or serious threat the time frame for review would revert to the general five days for response. The court determined that when the primary treating physician has marked the need for review to be expedited, then any response indicating the request for expedited response was not reasonably supported by the evidence would need to come within the 72-hour timeframe and come from a medical professional. Defendants retrospective review of the evidence supporting the lack of exigency will be considered untimely and subject the treatment requested to review by the court as opposed to any reliance on the UR determination and IMR requirements.

In Solano v. Shilo Ranch (2024) Cal.Wrk.Comp P.D. Lexis 280, the issue of UR review was addressed again. In this instance, Defendant attempted to recover payments made for transitional care that was responded to with a denial under the general 5/14-day timeframe for response. The defendant had authorized 14 days of inpatient care at Casa Colina. Applicant was noted to have suffered a traumatic brain injury with cognitive impairment, vision and hearing deficits that required the initial 14 day in patient authorization. A subsequent request for continue care was denied through Utilization Review. Applicant did not request IMR review of that request. The court considered whether the request should have been responded to within 72 hours for treatment involving the imminent or serious threat of life based on the nature of injury and treatment being requested. They determined the response provided at 5 days, to be untimely allowing the court to consider the medical necessity of that treatment request.

The facts do not confirm whether the request itself documented the need for an expedited response, but the court inferred from the facts of the request that an imminent or serious threat was present. The lack of response within 72 hours allowed the court to determine the UR response untimely allowing them to address the medical necessity of the requested care. Thus, where circumstances indicate the need for an expedited response, one should be considered and may be required by the facts.

In addition to the untimely nature of the UR response outlined by the court, they also relied on Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910, in that, treatment authorized cannot be discontinued without the defendant documenting a change in circumstances allowing for that discontinuation of care. Patterson involved authorization of a nurse case manager without documented termination of the timeframe for services. Once authorized the defendant was required to show a change in circumstances prior to allowance for the services to be discontinued. The Shilo court did not identify a distinction as to the timeframe limitation of the initial authorization in their case (14 days) and may still require a defendant to document a change in circumstances in order to deny care once authorized or establish that Labor Code section 4910((i)(4)(C) has been satisfied. This is a showing that the treating physician had been notified of the adverse decision and that a care plan had been agreed upon that would be appropriate for the needs of the employee. 

The key takeaways from these cases imply that the claims examiner should scrutinize RFAs that contemplate an imminent or serious threat to life. Any request that is requested on an expedited basis should be addressed by a medical professional within the 72-hour period to document whether a 5/14 day response would be appropriate. Facts of a case that suggest an imminent or serious threat to life should be considered for a 72-hour review. If an RFA requests an extension of treatment previously authorized, review the facts with the UR medical professional to document a change in circumstances that outline denial of additional care or discuss that declination of treatment with the PTP to confirm an alternate discharge from care has been addressed.