Labor Code Section 4610. (a) For purposes of this section, "utilization review" means utilization review or utilization
management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based
in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, as defined in Section
3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Section 4600.
(b) Every employer shall establish a utilization review process in compliance with this section, either directly or through its
insurer or an entity with which an employer or insurer contracts for these services.
(c) Each utilization review process shall be governed by written policies and procedures. These policies and procedures shall
ensure that decisions based on the medical necessity to cure and relieve of proposed medical treatment services are consistent
with the schedule for medical treatment utilization adopted pursuant to Section
5307.27. Prior to adoption of the schedule, these policies and procedures shall be consistent with the recommended standards
set forth in the American College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines.
These policies and procedures, and a description of the utilization process, shall be filed with the administrative director and
shall be disclosed by the employer to employees, physicians, and the public upon request.
(d) If an employer, insurer, or other entity subject to this section requests medical information from a physician in order to
determine whether to approve, modify, delay, or deny requests for authorization, the employer shall request only the
information reasonably necessary to make the determination. The employer, insurer, or other entity shall employ or designate a
medical director who holds an unrestricted license to practice medicine in this state
issued pursuant to Section 2050 or Section 2450 of the Business and Professions Code. The medical director shall ensure that
the process by which the employer or other entity reviews and approves, modifies, delays, or denies requests by physicians
prior to, retrospectively, or concurrent with the provision of medical treatment services, complies with the requirements of this
section. Nothing in this section shall be construed as restricting the existing authority of the Medical Board of California.
(e) No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical
treatment services, and where these services are within the scope of the physician's practice, requested by the physician may
modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve.
(f) The criteria or guidelines used in the utilization review process to determine whether to approve, modify, delay, or deny
medical treatment services shall be all of the following:
(1) Developed with involvement from actively practicing physicians.
(2) Consistent with the schedule for medical treatment utilization adopted pursuant to Section 5307.27. Prior to adoption of
the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the American
College of Occupational and Environmental Medicine Occupational Medical Practice
Guidelines.
(3) Evaluated at least annually, and updated if necessary.
(4) Disclosed to the physician and the employee, if used as the basis of a decision to modify, delay, or deny services in a
specified case under review.
(5) Available to the public upon request. An employer shall only be required to disclose the criteria or guidelines for the
specific procedures or conditions requested. An employer may charge members of the public reasonable copying and postage
expenses related to disclosing criteria or guidelines pursuant to this paragraph. Criteria or guidelines may also be made available
through electronic means. No charge shall be required for an employee whose physician's request for medical treatment services
is under review.
(g) In determining whether to approve, modify, delay, or deny requests by physicians prior to, retrospectively, or concurrent
with the provisions of medical treatment services to employees all of the following requirements must be met:
(1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the employee's
condition, not to exceed five working days from the receipt of the information reasonably necessary to make the determination,
but in no event more than 14 days from the date of the medical treatment
recommendation by the physician. In cases where the review is retrospective, the decision shall be communicated to the
individual who received services, or to the individual's designee, within 30 days of receipt of information that is reasonably
necessary to make this determination.
(2) When the employee's condition is such that the employee faces an imminent and serious threat to his or her health,
including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal time frame for the
decision making process, as described in paragraph (1), would be detrimental to the
employee's life or health or could jeopardize the employee's ability to regain maximum function, decisions to approve, modify,
delay, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees
shall be made in a timely fashion that is appropriate for the nature of the employee' s condition, but not to exceed 72 hours after
the receipt of the information reasonably necessary to make the determination.
(3) (A) Decisions to approve, modify, delay, or deny requests by physicians for authorization prior to, or concurrent with, the
provision of medical treatment services to employees shall be communicated to the requesting physician within 24 hours of the
decision. Decisions resulting in modification, delay, or denial of
all or part of the requested health care service shall be communicated to physicians initially by telephone or facsimile, and to the
physician and employee in writing within 24 hours for concurrent review, or within two business days of the decision for
prospective review, as prescribed by the administrative director. If the request is not approved in full, disputes shall be
resolved in accordance with Section 4062. If a request to perform spinal surgery is denied, disputes shall be resolved in
accordance with subdivision (b) of Section 4062.
(B) In the case of concurrent review, medical care shall not be discontinued until the employee's physician has been notified of
the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of the employee.
Medical care provided during a concurrent review shall be care that is medically
necessary to cure and relieve, and an insurer or self-insured employer shall only be liable for those services determined medically
necessary to cure and relieve. If the insurer or self-insured employer disputes whether or not one or more services offered
concurrently with a utilization review were medically necessary to cure and relieve, the dispute shall be resolved pursuant to
Section 4062, except in cases involving recommendations for the performance of spinal surgery, which shall be governed by the
provisions of subdivision (b) of Section 4062. Any compromise between the parties that an insurer or self-insured employer
believes may result in payment for services that were not medically necessary to cure and relieve shall be reported by the
insurer or the self-insured employer to the licensing board of the provider or providers who received the payments, in a manner
set forth by the respective board and in such a way as to minimize reporting costs both to the board and to the insurer or
self-insured employer, for evaluation as to possible violations of the statutes governing appropriate professional
practices. No fees shall be levied upon insurers or self-insured employers making reports required by this section.
(4) Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment service
approved. Responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians shall
include a clear and concise explanation of the reasons for the employer's
decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.
(5) If the employer, insurer, or other entity cannot make a decision within the timeframes specified in paragraph (1) or (2)
because the employer or other entity is not in receipt of all of the information reasonably necessary and requested, because the
employer requires consultation by an expert reviewer, or because the employer has asked that an additional examination or test
be performed upon the employee that is reasonable and consistent with good medical practice, the employer shall immediately
notify the physician and the employee, in writing, that the employer cannot make a decision within the required timeframe, and
specify the information requested
but not received, the expert reviewer to be consulted, or the additional examinations or tests required. The employer shall also
notify the physician and employee of the anticipated date on which a decision may be rendered. Upon receipt of all
information reasonably necessary and requested by the employer, the employer shall approve, modify, or deny the request for
authorization within the timeframes specified in paragraph (1) or (2).
(h) Every employer, insurer, or other entity subject to this section shall maintain telephone access for physicians to request
authorization for health care services.
(i) If the administrative director determines that the employer, insurer, or other entity subject to this section has failed to meet
any of the timeframes in this section, or has failed to meet any other requirement of this section, the administrative director may
assess, by order, administrative penalties for each failure. A proceeding for the issuance of an order assessing administrative
penalties shall be subject to appropriate notice to, and an opportunity for a hearing with regard to, the person affected. The
administrative penalties shall not be deemed to be an exclusive remedy for the administrative director. These penalties shall be
deposited in the Workers' Compensation Administration Revolving Fund.
management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based
in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, as defined in Section
3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Section 4600.
(b) Every employer shall establish a utilization review process in compliance with this section, either directly or through its
insurer or an entity with which an employer or insurer contracts for these services.
(c) Each utilization review process shall be governed by written policies and procedures. These policies and procedures shall
ensure that decisions based on the medical necessity to cure and relieve of proposed medical treatment services are consistent
with the schedule for medical treatment utilization adopted pursuant to Section
5307.27. Prior to adoption of the schedule, these policies and procedures shall be consistent with the recommended standards
set forth in the American College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines.
These policies and procedures, and a description of the utilization process, shall be filed with the administrative director and
shall be disclosed by the employer to employees, physicians, and the public upon request.
(d) If an employer, insurer, or other entity subject to this section requests medical information from a physician in order to
determine whether to approve, modify, delay, or deny requests for authorization, the employer shall request only the
information reasonably necessary to make the determination. The employer, insurer, or other entity shall employ or designate a
medical director who holds an unrestricted license to practice medicine in this state
issued pursuant to Section 2050 or Section 2450 of the Business and Professions Code. The medical director shall ensure that
the process by which the employer or other entity reviews and approves, modifies, delays, or denies requests by physicians
prior to, retrospectively, or concurrent with the provision of medical treatment services, complies with the requirements of this
section. Nothing in this section shall be construed as restricting the existing authority of the Medical Board of California.
(e) No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical
treatment services, and where these services are within the scope of the physician's practice, requested by the physician may
modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve.
(f) The criteria or guidelines used in the utilization review process to determine whether to approve, modify, delay, or deny
medical treatment services shall be all of the following:
(1) Developed with involvement from actively practicing physicians.
(2) Consistent with the schedule for medical treatment utilization adopted pursuant to Section 5307.27. Prior to adoption of
the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the American
College of Occupational and Environmental Medicine Occupational Medical Practice
Guidelines.
(3) Evaluated at least annually, and updated if necessary.
(4) Disclosed to the physician and the employee, if used as the basis of a decision to modify, delay, or deny services in a
specified case under review.
(5) Available to the public upon request. An employer shall only be required to disclose the criteria or guidelines for the
specific procedures or conditions requested. An employer may charge members of the public reasonable copying and postage
expenses related to disclosing criteria or guidelines pursuant to this paragraph. Criteria or guidelines may also be made available
through electronic means. No charge shall be required for an employee whose physician's request for medical treatment services
is under review.
(g) In determining whether to approve, modify, delay, or deny requests by physicians prior to, retrospectively, or concurrent
with the provisions of medical treatment services to employees all of the following requirements must be met:
(1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the employee's
condition, not to exceed five working days from the receipt of the information reasonably necessary to make the determination,
but in no event more than 14 days from the date of the medical treatment
recommendation by the physician. In cases where the review is retrospective, the decision shall be communicated to the
individual who received services, or to the individual's designee, within 30 days of receipt of information that is reasonably
necessary to make this determination.
(2) When the employee's condition is such that the employee faces an imminent and serious threat to his or her health,
including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal time frame for the
decision making process, as described in paragraph (1), would be detrimental to the
employee's life or health or could jeopardize the employee's ability to regain maximum function, decisions to approve, modify,
delay, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees
shall be made in a timely fashion that is appropriate for the nature of the employee' s condition, but not to exceed 72 hours after
the receipt of the information reasonably necessary to make the determination.
(3) (A) Decisions to approve, modify, delay, or deny requests by physicians for authorization prior to, or concurrent with, the
provision of medical treatment services to employees shall be communicated to the requesting physician within 24 hours of the
decision. Decisions resulting in modification, delay, or denial of
all or part of the requested health care service shall be communicated to physicians initially by telephone or facsimile, and to the
physician and employee in writing within 24 hours for concurrent review, or within two business days of the decision for
prospective review, as prescribed by the administrative director. If the request is not approved in full, disputes shall be
resolved in accordance with Section 4062. If a request to perform spinal surgery is denied, disputes shall be resolved in
accordance with subdivision (b) of Section 4062.
(B) In the case of concurrent review, medical care shall not be discontinued until the employee's physician has been notified of
the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of the employee.
Medical care provided during a concurrent review shall be care that is medically
necessary to cure and relieve, and an insurer or self-insured employer shall only be liable for those services determined medically
necessary to cure and relieve. If the insurer or self-insured employer disputes whether or not one or more services offered
concurrently with a utilization review were medically necessary to cure and relieve, the dispute shall be resolved pursuant to
Section 4062, except in cases involving recommendations for the performance of spinal surgery, which shall be governed by the
provisions of subdivision (b) of Section 4062. Any compromise between the parties that an insurer or self-insured employer
believes may result in payment for services that were not medically necessary to cure and relieve shall be reported by the
insurer or the self-insured employer to the licensing board of the provider or providers who received the payments, in a manner
set forth by the respective board and in such a way as to minimize reporting costs both to the board and to the insurer or
self-insured employer, for evaluation as to possible violations of the statutes governing appropriate professional
practices. No fees shall be levied upon insurers or self-insured employers making reports required by this section.
(4) Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment service
approved. Responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians shall
include a clear and concise explanation of the reasons for the employer's
decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.
(5) If the employer, insurer, or other entity cannot make a decision within the timeframes specified in paragraph (1) or (2)
because the employer or other entity is not in receipt of all of the information reasonably necessary and requested, because the
employer requires consultation by an expert reviewer, or because the employer has asked that an additional examination or test
be performed upon the employee that is reasonable and consistent with good medical practice, the employer shall immediately
notify the physician and the employee, in writing, that the employer cannot make a decision within the required timeframe, and
specify the information requested
but not received, the expert reviewer to be consulted, or the additional examinations or tests required. The employer shall also
notify the physician and employee of the anticipated date on which a decision may be rendered. Upon receipt of all
information reasonably necessary and requested by the employer, the employer shall approve, modify, or deny the request for
authorization within the timeframes specified in paragraph (1) or (2).
(h) Every employer, insurer, or other entity subject to this section shall maintain telephone access for physicians to request
authorization for health care services.
(i) If the administrative director determines that the employer, insurer, or other entity subject to this section has failed to meet
any of the timeframes in this section, or has failed to meet any other requirement of this section, the administrative director may
assess, by order, administrative penalties for each failure. A proceeding for the issuance of an order assessing administrative
penalties shall be subject to appropriate notice to, and an opportunity for a hearing with regard to, the person affected. The
administrative penalties shall not be deemed to be an exclusive remedy for the administrative director. These penalties shall be
deposited in the Workers' Compensation Administration Revolving Fund.
| Labor Code Section 4610 |
State Comp. Ins. Fund v. Workers' Comp. Appeals Bd., S149257, SUPREME COURT OF CALIFORNIA, July 3, 2008, Filed
Download in Work Doc
Download in PDF
“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.
Download in Work Doc
Download in PDF
“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.
 |  |  |  |