ADJ11235520 · June 22, 2026

The record did not establish whether defendant timely and properly communicated the June 6, 2022 request for additional information, creating an evidentiary gap preventing determination of timeliness of the June 10, 2022 UR denial. The case was remanded for further evidentiary development to resolve this issue.

From the decision · page 6Defendant relies on a UR request for additional information dated June 6, 2022, to support application of the extended timeframe under section 4610(j)(2). However, the determinative question is not merely the date appearing on the document, but whether the request was actually and immediately communicated to the treating physician and the employee within the statutory timeframe.

Defendant did not provide evidence of timely and proper communication of the June 6, 2022 request for additional information as required by Labor Code section 4610(j)(2).

Favours Applicant prevailed

This evidentiary gap prevented the Board from determining whether the June 10, 2022 UR denial was timely, necessitating remand for further proceedings.

From the decision · page 6On this record, there is a material evidentiary gap as to that issue. The record does not contain documentation establishing when, or if, defendant transmitted the June 6, 2022 UR request for information. There is no facsimile confirmation, electronic transmission record, or other proof demonstrating timely delivery. At the same time, the record includes an envelope with a barely legible June 13, 2022 postmark, which may suggest that defendant did not mail written notice until after the expiration of the five-business-day period. However, the record does not establish whether defendant utilized other forms of transmission such as facsimile or electronic mail prior to that date.

Diagnosed Minor Neurocognitive Disorder from the January 11, 2018 industrial motor vehicle accident, noting cognitive weaknesses and severe depression and anxiety related to chronic pain and sleep issues, recommending psychotherapeutic services and psychiatric consultation.

From the decision · page 2(MOH/SOE, 11/16/2022, 2:14-22.) In his report dated March 31, 2022, Fernando Gonzalez, Ph.D., after his evaluation of

Requested inpatient evaluation at Casa Colina Apple Valley for traumatic brain injury, citing objective clinical markers of impairment including abnormal memory tests and MRI findings.

His RFA was central to the timeliness dispute of the UR denial.

From the decision · page 3Dr. Bertoldi requested in his RFA "Inpatient evaluation Casa Colina Apple Valley" dated May 25, 2022 to address applicant's traumatic brain injury. (App. Ex. 3, p. 3). In the accompanying primary treating physician's progress report dated May 25, 2022, Dr. Bertoldi identified several objective clinical markers of impairment, including "abnormal" long and short-term memory, an abnormal Mini-Mental State Examination score of 23/30, and a 3 Tesla MRI showing posttraumatic Unidentified Bright Objects. (Id. at p. 2.) He supported the request for evaluation at Casa Colina Apple Valley by citing applicant's memory and concentration problems. (Ibid.) Dr. Bertoldi faxed the RFA on May 27, 2022. (Id. at p. 1.)

Reviewed medical records and denied the RFA on June 10, 2022, noting no response to the June 6, 2022 request for additional information.

His review and denial formed the basis of the timeliness dispute.

From the decision · page 4On June 10, 2022, defendant issued a "Notice of Modified Physician Determination," denying Dr. Bertoldi's RFA for an inpatient evaluation at Casa Colina Apple Valley. (Joint Ex. Z, p. 1.) The Notice is addressed to Dr. Bertoldi at his mailing address and lists his telephone and fax numbers. There is no indication how it was sent to Dr. Bertoldi. Under "Distribution," it states: "Applicant Attorney: Solov Teitell (via mail)" and "Employee: the applicant (via mail). (Id. at pp. 1-2.) The review by Mahdy Flores, D.O., stated that the date of service was June 10, 2022, and that the following medical records were reviewed: "Letter-UR_MD_Request (2 pgs)" and "05/25/22 RFA- Roger Bertoldi, MD (2 pgs)." It states that the Request for Information letter was reviewed, but it states that "a response was not submitted for this review." (Id. at p. 3.)

Labor Code section 4610; 8 CCR 9792.9.1(c)(4)

Labor Code section 4610 and related regulations govern the timing and communication requirements for utilization review decisions.

The Board applied these standards to determine whether the UR denial was timely and properly communicated.

From the decision · page 4UR governs an employer's evaluation of an employee's requests for medical treatment. (Lab. Code, § 4610(g); State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236 [73 Cal.Comp.Cases 981].) Section 4610 imposes mandatory time limits within which an employer must issue a UR decision. (Lab. Code, § 4610.)

Lack of documentation establishing when or if defendant transmitted the June 6, 2022 UR request for information, including no facsimile confirmation or electronic transmission record.

From the decision · page 6On this record, there is a material evidentiary gap as to that issue. The record does not contain documentation establishing when, or if, defendant transmitted the June 6, 2022 UR request for information. There is no facsimile confirmation, electronic transmission record, or other proof demonstrating timely delivery. At the same time, the record includes an envelope with a barely legible June 13, 2022 postmark, which may suggest that defendant did not mail written notice until after the expiration of the five-business-day period. However, the record does not establish whether defendant utilized other forms of transmission such as facsimile or electronic mail prior to that date.