ADJ11423609 · September 12, 2022

The February 2, 2022 utilization review certification was valid because it was based on a documented change in material facts, including additional imaging studies, which justified resubmission and certification despite a prior non-certification on January 11, 2022. The WCJ and WCAB found no error in authorizing the surgery based on the February 2, 2022 certification, and further utilization review was statutorily impermissible after certification.

From the decision · page 4A utilization review decision to modify or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to a further recommendation by the same physician, or another physician within the requesting physician's practice group, for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision.

The January 27, 2022 Request for Authorization was marked as a 'Resubmission - Change in Material Facts' and included additional radiographic imaging studies.

Favours Applicant prevailed

This justified resubmission to Utilization Review and led to the February 2, 2022 certification of the surgery as medically necessary, overriding the prior non-certification.

From the decision · page 4Here, the January 11, 2018 utilization review determination noted that the only medical records reviewed were that of Reza Omid, M.D., dated December 22, 2021, and the corresponding RFA, dated January 4, 2022. (Ex. D, Utilization Review denial, dated January 11, 2022, p. 3.) The stated rationale for non-certification included the lack of imaging studies, and the unsuccessful attempts at peer-to-peer discussion of the requested treatment. (Ibid.) Dr. Omid's January 27, 2022 resubmission of the RFA indicated the request was a "Resubmission - Change in Material Facts," and included the radiographic imaging studies comparison report authored by Ellen Chang, M.D.

The February 2, 2022 Utilization Review certification was based on the additional imaging studies and ongoing symptoms, supporting the medical necessity of the surgery.

Favours Applicant prevailed

This certification resolved the medical dispute and precluded further utilization review, leading to the WCJ order and WCAB decision authorizing the surgery.

From the decision · page 2On February 2, 2022, utilization review certified the RFA dated January 27, 2022 as medically necessary. (Ex. 1, Utilization Review (Genex, Review No. 5580302), dated February 2, 2022, p. 6.) The reviewing physician Donald Dinwoodie, M.D. noted that applicant's ongoing symptoms and corresponding diagnostic studies supported the certification of the requested reverse total arthroplasty surgery to the left shoulder. (Ibid.)

Recommended left-side reverse total shoulder arthroplasty based on ongoing symptoms and imaging confirming degenerative joint disease and pathology.

From the decision · page 2On December 22, 2021, applicant was evaluated by physician Reza Omid, M.D. for his continuing complaints to the left shoulder. (Ex. 3, report of Reza Omid, M.D., dated December 22, 2021, at p. 1.) The report noted a prior left shoulder surgery of December, 2018 with ongoing symptoms, including pain with overhead activities and applicant's reported inability to lift his arm above 90-degrees. (Ibid.) X-ray and MRI studies confirmed degenerative joint disease and ongoing pathology. (Id. at pp. 2-3.) Dr. Omid recommended a left-side reverse total shoulder arthroplasty be performed in order to "create a stable fulcrum of his shoulder." (Id. at p. 5.)

Certified the January 27, 2022 RFA as medically necessary based on ongoing symptoms and diagnostic studies; later issued a conflicting determination denying the surgery.

The February 2, 2022 certification was relied upon as it was supported by documented change in material facts, while the later denial was found statutorily impermissible.

From the decision · page 2On February 2, 2022, utilization review certified the RFA dated January 27, 2022 as medically necessary. (Ex. 1, Utilization Review (Genex, Review No. 5580302), dated February 2, 2022, p. 6.) The reviewing physician Donald Dinwoodie, M.D. noted that applicant's ongoing symptoms and corresponding diagnostic studies supported the certification of the requested reverse total arthroplasty surgery to the left shoulder. (Ibid.)

Labor Code section 4610

Labor Code section 4610 provides for the resolution of medical treatment disputes through Utilization Review, including the binding effect of utilization review decisions for 12 months unless there is a documented change in material facts.

The February 2, 2022 utilization review certification was valid because it was based on a documented change in material facts, including additional imaging studies, which justified resubmission and certification despite a prior non-certification on January 11, 2022.

From the decision · page 4A utilization review decision to modify or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to a further recommendation by the same physician, or another physician within the requesting physician's practice group, for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision.

Labor Code section 4604

Labor Code section 4604 vests the WCAB with authority to resolve non-medical disputes arising out of the utilization review process.

Defendant voluntarily submitted the matter as a medical dispute under section 4610 for further utilization review, waiving objection under section 4610(k).

From the decision · page 4However, section 4604 continues to vest with the Workers' Compensation Appeals Board (WCAB) the authority to resolve non-medical disputes arising out of the utilization review process. Section 4604 provides that: "[c]ontroversies between employer and employee arising under this chapter shall be determined by the appeals board, upon the request of either party, except as otherwise provided by Section 4610.5." (Italics added.) (Dubon v. World Restoration (2014) (79 Cal. Comp. Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131] (Appeals Bd. en banc).)

Labor Code section 4610.5

Labor Code section 4610.5 provides that if utilization review approves the requested treatment, the determination is final and the employer may not challenge it.

The February 2, 2022 certification resolved the medical dispute and precluded further utilization review on the approved treatment.

Applicant testified he received both an authorization and a denial of the requested shoulder surgery in February 2022.

From the decision · page 3Evidence (Minutes), at 2:17.) Applicant testified that in February, 2022, he received both an authorization and a denial of the requested shoulder surgery. (Id. at 6:11.)