ADJ11091794 — California WCAB decision

What the panel ordered

The Petition for Reconsideration filed by Defendant was denied.

Defendant filed a Petition for Reconsideration of the Findings of Fact and Order issued on April 27, 2022, which was denied by the WCAB panel on July 5, 2022.

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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.

Medical treatment / UR / IMRApplicant prevailedleft L3,4

The WCJ and panel found that the left L3,4 TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary based on medical reports from Dr. Rho and other providers demonstrating the treatment was required to cure or relieve the injured worker's condition.

From the decision · page 6Turning to defendant's contention that the WCJ erroneously determined that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary, we agree with the WCJ's reasoning, as stated in the Report, that the medical reports from Dr. Rho, Casa Colina, and Learning Services Home and Community demonstrate that the treatment sought by the June 9, 20201 RFA is reasonably required to cure or relieve the injured worker from the effects of his injury. Accordingly, we are unable to discern error in the WCJ's finding that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

The UR determinations of Dr. Patterson's May 17, 2021 RFA were not timely communicated to applicant or applicant's PTP as required by Labor Code section 4610.

Favours Applicant prevailed

This lack of timely communication rendered the UR determinations untimely, allowing the WCAB to determine medical necessity, favoring the applicant.

From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...

Medical reports from Dr. Rho and other providers demonstrated the left L3,4 TFE injection was reasonably required to cure or relieve the injured worker's condition.

Favours Applicant prevailed

This supported the WCJ's finding that the treatment was reasonable and necessary, favoring the applicant.

From the decision · page 6Turning to defendant's contention that the WCJ erroneously determined that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary, we agree with the WCJ's reasoning, as stated in the Report, that the medical reports from Dr. Rho, Casa Colina, and Learning Services Home and Community demonstrate that the treatment sought by the June 9, 20201 RFA is reasonably required to cure or relieve the injured worker from the effects of his injury. Accordingly, we are unable to discern error in the WCJ's finding that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary.

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.

PTPRelied upon

Dr. Rho's June 9, 2021 RFA for left L3,4 TFE injection was found reasonable and necessary based on medical reports.

The WCJ and panel relied on medical reports from Dr. Rho and other providers to find the treatment reasonable and necessary.

From the decision · page 6Turning to defendant's contention that the WCJ erroneously determined that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary, we agree with the WCJ's reasoning, as stated in the Report, that the medical reports from Dr. Rho, Casa Colina, and Learning Services Home and Community demonstrate that the treatment sought by the June 9, 20201 RFA is reasonably required to cure or relieve the injured worker from the effects of his injury. Accordingly, we are unable to discern error in the WCJ's finding that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary.

PTPRelied upon

Dr. Patterson's May 17, 2021 RFA was the subject of a Utilization Review determination found untimely due to lack of timely communication as required by Labor Code section 4610.

The WCJ and panel relied on the lack of timely communication of the UR determination related to Dr. Patterson's RFA to find the UR untimely.

From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code section 4610

Labor Code section 4610 requires timely communication of Utilization Review decisions to the requesting physician and injured worker or their attorney.

The WCJ and panel applied this standard to find the UR determinations untimely due to lack of timely communication.

From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...

Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519

A UR decision that is timely made but not timely communicated is untimely and the Appeals Board has jurisdiction to determine medical necessity.

The panel applied this precedent to support the finding that the UR determinations were untimely due to lack of timely communication.

From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)

The Appeals Board has jurisdiction to determine whether a UR decision is timely and if untimely, may determine medical necessity.

The panel applied this en banc precedent to confirm jurisdiction over untimely UR determinations.

From the decision · page 4Section 4610 provides time limits within which a UR decision must be made by the employer. (§ 4610 et seq.) These time limits are mandatory. In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) (Dubon II), the Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) If the UR decision is timely, the Appeals Board has no jurisdiction to address disputes regarding the UR because "[a]ll other disputes regarding a UR decision must be resolved by IMR." (Id. at p. 1299.)

Labor Code section 4600(a)

Labor Code section 4600(a) requires employers to provide reasonable medical treatment to cure or relieve effects of industrial injury.

The panel applied this standard to find the left L3,4 TFE injection reasonable and necessary.

From the decision · page 4Labor Code section 46001 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (§ 4600(a).) Employers are required to establish a UR process for treatment requests received from physicians. (§ 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.)

ADJ11091794 · July 5, 2022

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

What the panel did with the medical opinions

The rules the panel named

What proof carried it

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