SHORT LESSON ONE ON UTILIZATION REVIEW
Utilization Review to Deny Medical Treatment is mandatory and the defendants failure to perform a
utilization review after a request for authorization precludes the defendants from using any medical
legal reports to show the treatment was not reasonable and necessary
State Comp. Ins. Fund v. Workers' Comp. Appeals Bd., S149257, SUPREME COURT OF
CALIFORNIA, 2008 Cal. LEXIS 7905, July 3, 2008, Filed
“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.”
Utilization Review to Deny Medical Treatment is mandatory and the defendants failure to perform a
utilization review after a request for authorization precludes the defendants from using any medical
legal reports to show the treatment was not reasonable and necessary
State Comp. Ins. Fund v. Workers' Comp. Appeals Bd., S149257, SUPREME COURT OF
CALIFORNIA, 2008 Cal. LEXIS 7905, July 3, 2008, Filed
“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.”
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