Labor Code section 4062. (a) If either the employee or employer objects to a medical determination made by the treating physician
concerning any medical issues not covered by Section 4060 or 4061 and not subject to Section 4610, the objecting party shall
notify the other party in writing of the objection within 20 days of receipt of the report if the employee is represented by an
attorney or within 30 days of receipt of the report if the employee is not represented by an attorney. Employer objections to the
treating physician's recommendation for spinal surgery shall be subject to subdivision (b), and after denial of the physician's
recommendation, in accordance with Section 4610. If the employee objects to a decision made pursuant to Section 4610 to modify,
delay, or deny a treatment recommendation, the employee shall notify the employer of the objection in writing within 20 days
of receipt of that decision. These time limits may be extended for good cause or by mutual agreement. If the employee is
represented by an attorney, a medical evaluation to determine the disputed medical issue shall be obtained as provided in Section
4062.2, and no other medical evaluation shall be obtained. If the employee is not represented by an attorney, the employer shall
immediately provide the employee with a form prescribed by the medical director with which to request assignment of a panel of
three qualified medical evaluators, the evaluation shall be obtained as provided in Section 4062.1, and no other medical evaluation
shall be obtained.
(b) The employer may object to a report of the treating physician recommending that spinal surgery be performed within 10 days
of the receipt of the report. If the employee is represented by an attorney, the parties shall seek agreement with the other party on
a California licensed board-certified or board-eligible orthopedic surgeon or neurosurgeon to prepare a second opinion report
resolving the disputed surgical recommendation. If no agreement is reached within 10 days, or if the employee is not represented
by an attorney, an orthopedic surgeon or neurosurgeon shall be randomly selected by the administrative director to prepare a
second opinion report resolving the disputed surgical recommendation. Examinations shall be scheduled on an expedited basis. The
second opinion report shall be served on the parties within 45 days of receipt of the treating physician's report. If the second
opinion report recommends surgery, the employer shall authorize the surgery. If the second opinion report does not recommend
surgery, the employer shall file a
declaration of readiness to proceed. The employer shall not be liable for medical treatment costs for the disputed surgical
procedure, whether through a lien filed with the appeals board or as
a self-procured medical expense, or for periods of temporary disability resulting from the surgery, if the disputed surgical
procedure is performed prior to the completion of the second opinion
process required by this subdivision.
(c) The second opinion physician shall not have any material professional, familial, or financial affiliation, as determined by the
administrative director, with any of the following:
(1) The employer, his or her workers' compensation insurer, third-party claims administrator, or other entity contracted to provide
utilization review services pursuant to Section 4610.
(2) Any officer, director, or employee of the employer's health care provider, workers' compensation insurer, or third-party claims
administrator.
(3) A physician, the physician's medical group, or the independent practice association involved in the health care service in
dispute.
(4) The facility or institution at which either the proposed health care service, or the alternative service, if any, recommended by
the employer's health care provider, workers' compensation
insurer, or third-party claims administrator, would be provided.
(5) The development or manufacture of the principal drug, device, procedure, or other therapy proposed by the employee or his or
her treating physician whose treatment is under review, or the
alternative therapy, if any, recommended by the employer or other entity.
(6) The employee or the employee's immediate family.
concerning any medical issues not covered by Section 4060 or 4061 and not subject to Section 4610, the objecting party shall
notify the other party in writing of the objection within 20 days of receipt of the report if the employee is represented by an
attorney or within 30 days of receipt of the report if the employee is not represented by an attorney. Employer objections to the
treating physician's recommendation for spinal surgery shall be subject to subdivision (b), and after denial of the physician's
recommendation, in accordance with Section 4610. If the employee objects to a decision made pursuant to Section 4610 to modify,
delay, or deny a treatment recommendation, the employee shall notify the employer of the objection in writing within 20 days
of receipt of that decision. These time limits may be extended for good cause or by mutual agreement. If the employee is
represented by an attorney, a medical evaluation to determine the disputed medical issue shall be obtained as provided in Section
4062.2, and no other medical evaluation shall be obtained. If the employee is not represented by an attorney, the employer shall
immediately provide the employee with a form prescribed by the medical director with which to request assignment of a panel of
three qualified medical evaluators, the evaluation shall be obtained as provided in Section 4062.1, and no other medical evaluation
shall be obtained.
(b) The employer may object to a report of the treating physician recommending that spinal surgery be performed within 10 days
of the receipt of the report. If the employee is represented by an attorney, the parties shall seek agreement with the other party on
a California licensed board-certified or board-eligible orthopedic surgeon or neurosurgeon to prepare a second opinion report
resolving the disputed surgical recommendation. If no agreement is reached within 10 days, or if the employee is not represented
by an attorney, an orthopedic surgeon or neurosurgeon shall be randomly selected by the administrative director to prepare a
second opinion report resolving the disputed surgical recommendation. Examinations shall be scheduled on an expedited basis. The
second opinion report shall be served on the parties within 45 days of receipt of the treating physician's report. If the second
opinion report recommends surgery, the employer shall authorize the surgery. If the second opinion report does not recommend
surgery, the employer shall file a
declaration of readiness to proceed. The employer shall not be liable for medical treatment costs for the disputed surgical
procedure, whether through a lien filed with the appeals board or as
a self-procured medical expense, or for periods of temporary disability resulting from the surgery, if the disputed surgical
procedure is performed prior to the completion of the second opinion
process required by this subdivision.
(c) The second opinion physician shall not have any material professional, familial, or financial affiliation, as determined by the
administrative director, with any of the following:
(1) The employer, his or her workers' compensation insurer, third-party claims administrator, or other entity contracted to provide
utilization review services pursuant to Section 4610.
(2) Any officer, director, or employee of the employer's health care provider, workers' compensation insurer, or third-party claims
administrator.
(3) A physician, the physician's medical group, or the independent practice association involved in the health care service in
dispute.
(4) The facility or institution at which either the proposed health care service, or the alternative service, if any, recommended by
the employer's health care provider, workers' compensation
insurer, or third-party claims administrator, would be provided.
(5) The development or manufacture of the principal drug, device, procedure, or other therapy proposed by the employee or his or
her treating physician whose treatment is under review, or the
alternative therapy, if any, recommended by the employer or other entity.
(6) The employee or the employee's immediate family.
| Labor Code section 4062 |
State Comp. Ins. Fund v. Workers' Comp. Appeals Bd., S149257, SUPREME COURT OF CALIFORNIA, July 3, 2008, Filed
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“The insurer referred the matter for utilization review but did not communicate its decision within the 14-day statutory deadline
set forth in § 4610, subd. (g)(1). A workers' compensation judge found that the insurer's failure to comply with the statutory
deadlines precluded it from relying on the utilization review process or on its doctor's report to deny the requested treatment”
“Thus, employers and their insurers could not use § 4062 as an alternative method for disputing employees' treatment requests.
Only an employee could use the provisions of § 4062 to resolve a dispute over a treatment request; an employer could not do so.”
Lien Claimant requested authorization and utilization review a response was not given within the time frame allowable which
precluded defense from relaying on any medical reports to deny treatment.
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“The insurer referred the matter for utilization review but did not communicate its decision within the 14-day statutory deadline
set forth in § 4610, subd. (g)(1). A workers' compensation judge found that the insurer's failure to comply with the statutory
deadlines precluded it from relying on the utilization review process or on its doctor's report to deny the requested treatment”
“Thus, employers and their insurers could not use § 4062 as an alternative method for disputing employees' treatment requests.
Only an employee could use the provisions of § 4062 to resolve a dispute over a treatment request; an employer could not do so.”
Lien Claimant requested authorization and utilization review a response was not given within the time frame allowable which
precluded defense from relaying on any medical reports to deny treatment.
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