Lisa Simmons vs. State of California, Dept of Mental Health (Metropolitan State Hospital), Legally Uninsured; and State Compensation
Insurance Fund (Adjusting Agent), June 17, 2005
En Banc (WCAB No. LBO 0340807) 70 Cal. Comp. Cases 866
With regard to Utilization Review, the Appeals Board held:
(1) If a defendant undertakes utilization review to determine whether a proposed treatment is medically necessary, and if the utilization review
physician finds that the treatment is medically necessary but raises questions as to whether the treatment is industrially-related, the utilization
review report is admissible in evidence for the limited purposes of establishing: (a) utilization review was undertaken and the date(s) of the
utilization review physician's report(s); (b) the utilization review physician found the proposed treatment to be medically necessary; and (c) the
utilization review process has resulted in a dispute as to whether the industrial injury caused or contributed to the need for the treatment;
(2) A utilization review physician finds that a treatment is medically necessary but questions whether the need for that treatment is causally
related to the industrial injury, the defendant must either: (a) authorize the treatment;
or
(b) timely deny authorization based on causation within the deadlines set forth in section 4610(g)(1); timely communicate the denial based on
causation to both the treating physician and the applicant within the deadlines set forth in section 4610(g)(3)(A); and timely initiate the
AME/QME process within 20 days of the receipt of the utilization of physician's report, if the employee is represented by an attorney, or 30
days, if the employee is unrepresented, in accordance with section 4062(a)*; and
(4) Although the ACOEM guidelines are "presumptively correct on the issue of extent and scope of medical treatment" (Lab.Code 4604.5(c), they
are not presumptively correct on the issue of whether a need for medical treatment is causally related to the industrial injury.
* In reaching this holding, we are not addressing any issues relating to proposed spinal surgery under sections 4610(g)(3)(A) & (B) and 4062(b).
Insurance Fund (Adjusting Agent), June 17, 2005
En Banc (WCAB No. LBO 0340807) 70 Cal. Comp. Cases 866
With regard to Utilization Review, the Appeals Board held:
(1) If a defendant undertakes utilization review to determine whether a proposed treatment is medically necessary, and if the utilization review
physician finds that the treatment is medically necessary but raises questions as to whether the treatment is industrially-related, the utilization
review report is admissible in evidence for the limited purposes of establishing: (a) utilization review was undertaken and the date(s) of the
utilization review physician's report(s); (b) the utilization review physician found the proposed treatment to be medically necessary; and (c) the
utilization review process has resulted in a dispute as to whether the industrial injury caused or contributed to the need for the treatment;
(2) A utilization review physician finds that a treatment is medically necessary but questions whether the need for that treatment is causally
related to the industrial injury, the defendant must either: (a) authorize the treatment;
or
(b) timely deny authorization based on causation within the deadlines set forth in section 4610(g)(1); timely communicate the denial based on
causation to both the treating physician and the applicant within the deadlines set forth in section 4610(g)(3)(A); and timely initiate the
AME/QME process within 20 days of the receipt of the utilization of physician's report, if the employee is represented by an attorney, or 30
days, if the employee is unrepresented, in accordance with section 4062(a)*; and
(4) Although the ACOEM guidelines are "presumptively correct on the issue of extent and scope of medical treatment" (Lab.Code 4604.5(c), they
are not presumptively correct on the issue of whether a need for medical treatment is causally related to the industrial injury.
* In reaching this holding, we are not addressing any issues relating to proposed spinal surgery under sections 4610(g)(3)(A) & (B) and 4062(b).
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