Opinion ID: 1801902
Heading Depth: 3
Heading Rank: 1

Heading: Statutory Scheme Requires Employers to Conduct Utilization Review When Resolving Requests for Medical Treatment

Text: Section 4610 requires that [e]very employer ... establish a utilization review process in compliance with this section ( id., subd. (b)), defining utilization review as 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 ... ( id., subd. (a)). Notwithstanding the breadth of this statutory directive, State Fund claims that section 4610 simply requires employers to establish a utilization review process, but does not require employers to actually use the process. We find this argument unpersuasive. Having broadly defined utilization review, and requiring every employer to establish such a process at considerable expense and with numerous statutory safeguards (discussed in further detail below), it is unlikely that the Legislature intended to allow employers to circumvent the process whenever an employer felt it expedient. To the contrary, the statutory language indicates the Legislature intended for employers to use the utilization review process when reviewing and resolving any and all requests for medical treatment. (1) Believing that it can opt out of the review process, State Fund claims that it can instead utilize the more general section 4062 dispute resolution procedures. Not so. State Fund's assertion is belied by the language of section 4062 itself. The statute permits employers to object to a treating physician's medical determinations, but only to those determinations regarding medical issues not covered by Section 4060 or 4061 and not subject to Section 4610 .... (§ 4062, subd. (a), italics added.) By contrast, section 4062 explicitly permits employees to use its provisions to object to an employer's decision made pursuant to Section 4610 to modify, delay, or deny a treatment recommendation.... ( Id., subd. (a), italics added.) In summary, section 4062 simultaneously precludes employers from using its provisions to object to employees' treatment requests but permits employees to use its provisions to object to employers' decisions regarding treatment requests. The Legislature's intent regarding employers' use of section 4062 to dispute treatment requests could not be more clear. (2) Taken together, the language of sections 4610 and 4062 demonstrates that (1) the Legislature intended for employers to use the utilization review process in section 4610 to review and resolve any and all requests for treatment, and (2) if dissatisfied with an employer's decision, an employee (and only an employee) may use section 4062's provisions to resolve the dispute over the treatment request. An employer may not bypass the utilization review process and instead invoke section 4062's provisions to dispute an employee's treatment request. The correctness of this conclusion is particularly evident when the current statutory provisions are compared to prior schemes for handling employees' treatment requests.