What the panel ordered
Reconsideration granted, WCJ's Findings rescinded, and matter returned to WCJ for further proceedings and new decision.
Applicant sought reconsideration of the WCJ's August 7, 2023 Findings of Fact, which found applicant did not sustain his burden of proof as to the allegation of untimely UR.
What was disputed, and how it came out
Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.
There was insufficient evidence in the record to determine whether the UR was timely, as threshold documents (RFA and medical report with proof of service) were not admitted into evidence.
From the decision · page 4Accordingly, we grant reconsideration, rescind the Findings, and return the matter to the WCJ for further proceedings consistent with this opinion, and to issue a new decision from which any aggrieved person may timely seek reconsideration.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The record did not contain the RFA or the medical report of Dr. Haronian dated 08-31-2022 with proof of service.
Favours neutral
Without these threshold documents, there was no factual basis to determine the timeliness of the UR Determination.
From the decision · page 3Applicant's attorney's asserts that the utilization review denial was untimely. The evidence submitted by applicant's attorney did not include the RFA or the medical report of Dr. Haronian dated 08-31-2022 with proof of service. These would be the threshold documents to start the utilization review analysis. (Opinion on Decision; see also Report, p. 3.)
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Requested left shoulder surgery and submitted appeal to UR Determination denial.
PTP's RFA and medical report were not admitted into evidence, so the timeliness of UR could not be determined.
From the decision · page 2HDi subsequently issued a UR Determination Denial dated September 8, 2022, denying the left shoulder surgery requested by Dr. Haronian. (Joint Exh. B.)2 Dr. Haronian submitted an Appeal to the UR Determination, "...requesting an appeal by an unbiased physician." (App. Exh. 1, Edwin Haronian, M.D., September 20, 2022, p. 2.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code, § 5952(d)
Any award, order or decision of the Appeals Board must be supported by substantial evidence.
The Appeals Board cannot determine the timeliness of UR without substantial evidence in the record.
Cal. Code Regs., tit. 8, § 9792.9.1(e)(3)
For prospective, concurrent, or expedited review, a decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and written notice to the requesting physician, the injured worker, and if represented, the injured worker's attorney within two business days for prospective review.
No evidence in the record that UR Determination Denial was served on applicant's counsel as required.
From the decision · page 3(3) For prospective, concurrent, or expedited review, a decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and shall be communicated to the requesting physician initially by telephone, facsimile, or electronic mail. The communication by telephone shall be followed by written notice to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney within 24 hours of the decision for concurrent review and within two (2) business days for prospective review and for expedited review within 72 hours of receipt of the request (Cal. Code Regs., tit. 8, § 9792.9.1(e)(3); see also § 9792.9.1(f)(4).)
What proof carried it
The evidence the panel weighed, by kind.
Absence of RFA and medical report of Dr. Haronian dated 08-31-2022 with proof of service in evidence prevented determination of UR timeliness.
From the decision · page 3Applicant's attorney's asserts that the utilization review denial was untimely. The evidence submitted by applicant's attorney did not include the RFA or the medical report of Dr. Haronian dated 08-31-2022 with proof of service. These would be the threshold documents to start the utilization review analysis. (Opinion on Decision; see also Report, p. 3.)
The same issues, filtered across the whole corpus — or paste your own facts and let the search rank by factor match.
About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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