Source: https://www.lexisnexis.com/legalnewsroom/workers-compensation/b/workers-compensation-law-blog/archive/2009/08/04/california-post_2d00_sandhagen-panel-decision-raises-new-questions-about-utilization-review.aspx?Redirected=true
Timestamp: 2017-10-19 17:24:34
Document Index: 125774945

Matched Legal Cases: ['§ 9792', '§ 9792', '§ 9792', '§ 9792', '§ 9792', '§ 9792']

Utilization Review (UR) is the process used by employers or claims administrators to review medical treatment requested for the injured worker to determine if the proposed treatment is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician.
UR begins when the request for authorization is first received, whether by the employer, claims administrator or utilization review organization (URO).
Authorization means assurance that appropriate reimbursement for a specific treatment will be paid. 8 CCR § 9792.6(b) sets forth how a doctor requests treatment, diagnostic tests or other medical services for an injured worker. A request for authorization may initially be made verbally, but it must be confirmed in writing within 72 hours of the doctor’s “First Report of Occupational Injury or Illness” (form DLSR 5021), the “Primary Treating Physician Progress Report” (DWC form PR-2), or in a narrative report that contains the same information required in the PR-2 form. If a narrative report is used, the document must be clearly marked at the top as a request for authorization. (8 CCR § 9792.6(o))
So the question in anticipation of further litigation with respect to this issue is: When an insurance company denies a claim without UR, and UR is requested, does that request for authorization turn into an implied authorization for the services if the claim is later determined to be industrially related? (There does not seem to be at this point an appellate decision dealing with this specific issue)
A non-physician reviewer may:
Request appropriate additional information necessary to render a decision (8 CCR § 9792.7(b)(3))
Approve a request for authorization (8 CCR § 9792.7(b)(3))
Discuss applicable medical guidelines with the requesting physician when requested treatment appears to be inconsistent with medical guidelines (8 CCR § 9792.7(b)(3))
The non-physician reviewer may discuss the treatment plan with the requesting physician. If the requesting physician decides to make a change in the treatment plan, the physician should provide documentation for that change. (8 CCR § 9792.7(b)(3))
The Vasquez case at first glance seems to resolve an issue of utilization review, but in this writer’s opinion, may well open up a flood gate of litigation against insurance carriers because of past practices of not properly conducting utilization review.
This blog was written by Reid Steinfeld, Esq. and Richard J. Boggan, J.D.
Regardless of school district's failure to conduct timely UR, doesn't applicant have evidentiary burden to establish the requested treatment is medically necessary and based upon ACOEM or other evidence/scientifically-based treatment guidelines per LC 4600 and 'Lamin v City of Los Angeles' 69 CCC 1002? What if a request for chiropractic treatment in excess of 24 visits was not timely processed by UR? Does defendant lose the ability to argue no entitlement to treatments in excess of 24 per LC 4604.5 as medically necessary issue is moot?