What the panel ordered
The Appeals Board denied defendant's Petition for Reconsideration, upholding the WCJ's Findings and Award that the utilization review decision was untimely and the requested inpatient rehabilitation treatment was reasonable and medically necessary.
Defendant filed a Petition for Reconsideration of the Findings and Award issued on September 5, 2025, challenging the timeliness of the utilization review decision and the medical necessity of requested treatment. The WCJ recommended denial of the Petition, and the Appeals Board reviewed and denied reconsideration on December 22, 2025.
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.
The Appeals Board found the requested inpatient rehabilitation treatment reasonable and medically necessary based on substantial medical evidence, including the RFA and supporting reports from Dr. Prasad and PQME Dr. Richman.
From the decision · page 8B. Although timely Utilization Review was not completed, applicant remains with the burden of establishing the treatment requested is reasonable. (Lab. Code § 5705.) For the treatment to be found industrial, the applicant must establish that the treatment is reasonable under the Medical Treatment Utilization Schedule (MTUS). (Lab. Code § 4600(b), 5307.27; Cal. Code Reg., title 8, § 9792.20-9292.27.23.) This is because "to carry this burden, the employee must present substantial medical evidence." (Dubon v. World Restoration, (2104) (Dubon II) 79 Cal.Comp.Cases 1298, 1312, (Appeals Board en banc).) The RFA at issue seeks inpatient post-acute comprehensive rehabilitation for traumatic brain injury (TBI).
The Appeals Board found the utilization review decision untimely because the time to conduct utilization review commenced on the date liability was determined (May 7, 2025), and the defendant issued the decision on May 15, 2025, exceeding the five business day limit.
From the decision · page 4A. Defendant seeks to have us read section 4610 as providing that the time to complete UR does not start until a body part dispute is resolved and applicant resends the original or new RFA to defendant. We decline to do so. As relevant here, section 4610 provides "[u]tilization review of a treatment recommendation shall not be required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended pursuant to Section 4062." (Lab. Code § 4610(l).) Further: (m) If utilization review is deferred pursuant to subdivision (l), and it is finally determined that the employer is liable for treatment of the condition for which treatment is recommended, the time for the employer to conduct retrospective utilization review in accordance with paragraph (2) of subdivision (i) shall begin on the date the determination of the employer's liability becomes final, and the time for the employer to conduct prospective utilization review shall commence from the date of the employer's receipt of a treatment recommendation after the determination of the employer's liability.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant's utilization review decision was issued on May 15, 2025, after the five business day deadline from May 7, 2025, the date liability was determined.
Favours Applicant prevailed
This untimeliness allowed the Appeals Board to consider the medical necessity of the requested treatment rather than deferring to the UR decision.
From the decision · page 5make the determination (in this case the determination of liability) on May 7, 2025. Therefore, defendant had five business days, without considering weekends, from May 7, 2025, or until May 14, 2025, to issue a decision.
The requested inpatient post-acute comprehensive rehabilitation treatment for traumatic brain injury is supported by substantial medical evidence including the RFA and reports from Dr. Prasad and PQME Dr. Richman.
Favours Applicant prevailed
This medical evidence established the treatment as reasonable and medically necessary under the MTUS, supporting the applicant's claim.
From the decision · page 8(Exhibit 3.) The relevant MTUS for traumatic brain injury recommends inpatient comprehensive integrated interdisciplinary rehabilitation when there are indications of "[s]ufficient residual symptoms and/or signs of mostly acute TBI to necessitate ongoing and daily treatment, be it medical, physical therapy, occupational therapy, or other." "Most patients will have incurred severe TBI, but occasionally, patients with moderate TBI may also be benefited by these programs." Frequency/Dose/Duration is listed as: "[h]ighly variable and depends on clinical status, including symptoms, signs, functional deficits, rate of progress, need for individualized care (e.g., coaching), etc." (Cal.
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.
Found industrial injuries including traumatic brain injury, lighting up of photogenic epilepsy, posttraumatic head syndrome, cerebral concussion, convergence insufficiency, posttraumatic headaches, and anxiety associated with hyperventilation syndrome. Equivocal about inpatient vs outpatient treatment but not opposed to inpatient treatment.
Provided substantial medical evidence supporting the need for inpatient rehabilitation treatment, though leaning towards outpatient treatment.
From the decision · page 3Defendant denied applicant's claim on June 27, 2022. (Exhibit G.) On December 4, 2023, defendant accepted applicant's injury to the head, neck, mouth/jaw, and teeth #6-11, while continuing to dispute the eyes, ears, nervous system, and brain. (Exhibit D.) Dr. Prasad was authorized to treat applicant's head and neck. (Exhibit 2). On February 12, 2024, Dr. Prasad issued an RFA seeking inpatient post-acute comprehensive rehabilitation for a diagnosis of TBI. (Exhibit 3.) Defendant deferred UR of the RFA on February 15, 2024, citing the brain as a disputed body part. (Exhibit 5.) On November 19, 2024, PQME Dr. Richman issued a report after evaluating the applicant finding industrial injuries of traumatic brain injury, lighting up of photogenic epilepsy,
Authorized to treat applicant's head and neck. Issued RFA seeking inpatient post-acute comprehensive rehabilitation for traumatic brain injury, supported by detailed medical reports.
RFA and attached reports constitute substantial medical evidence supporting the requested treatment.
From the decision · page 3Defendant denied applicant's claim on June 27, 2022. (Exhibit G.) On December 4, 2023, defendant accepted applicant's injury to the head, neck, mouth/jaw, and teeth #6-11, while continuing to dispute the eyes, ears, nervous system, and brain. (Exhibit D.) Dr. Prasad was authorized to treat applicant's head and neck. (Exhibit 2). On February 12, 2024, Dr. Prasad issued an RFA seeking inpatient post-acute comprehensive rehabilitation for a diagnosis of TBI. (Exhibit 3.) Defendant deferred UR of the RFA on February 15, 2024, citing the brain as a disputed body part. (Exhibit 5.) On November 19, 2024, PQME Dr. Richman issued a report after evaluating the applicant finding industrial injuries of traumatic brain injury, lighting up of photogenic epilepsy,
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code 4610; Cal. Code Reg., title 8, 9792.9.1(b)(2)
Utilization review time limits under Labor Code section 4610 and related regulations.
The time to conduct utilization review commences upon determination of liability and receipt of the RFA, with a five business day limit to issue a decision.
From the decision · page 4A. Defendant seeks to have us read section 4610 as providing that the time to complete UR does not start until a body part dispute is resolved and applicant resends the original or new RFA to defendant. We decline to do so. As relevant here, section 4610 provides "[u]tilization review of a treatment recommendation shall not be required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended pursuant to Section 4062." (Lab. Code § 4610(l).) Further: (m) If utilization review is deferred pursuant to subdivision (l), and it is finally determined that the employer is liable for treatment of the condition for which treatment is recommended, the time for the employer to conduct retrospective utilization review in accordance with paragraph (2) of subdivision (i) shall begin on the date the determination of the employer's liability becomes final, and the time for the employer to conduct prospective utilization review shall commence from the date of the employer's receipt of a treatment recommendation after the determination of the employer's liability.
Lab. Code 4600(a)
Employer's duty to provide reasonable medical treatment under Labor Code section 4600(a).
Employer must provide reasonable medical treatment to cure or relieve effects of industrial injury; UR decisions must be timely to be valid.
From the decision · page 7Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of the industrial injury. (Lab. Code, § 4600(a).) An employers' review of an employees' medical treatment requests is governed solely by UR. (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].) As noted above, section 4610 provides the time limits within which a UR decision must be made by the employer. (Lab. Code, § 4610.) These time limits are mandatory.
Lab. Code 5705; Cal. Code Reg., title 8, 9792.24.5; MTUS, American College of Occupational and Environmental Medicine, Traumatic Brain Injury, effective November 15, 2017
Burden of proof on applicant to establish treatment reasonableness under Labor Code section 5705 and MTUS guidelines.
Applicant must present substantial medical evidence to establish treatment is reasonable under MTUS for inpatient rehabilitation.
From the decision · page 8B. Although timely Utilization Review was not completed, applicant remains with the burden of establishing the treatment requested is reasonable. (Lab. Code § 5705.) For the treatment to be found industrial, the applicant must establish that the treatment is reasonable under the Medical Treatment Utilization Schedule (MTUS). (Lab. Code § 4600(b), 5307.27; Cal. Code Reg., title 8, § 9792.20-9292.27.23.) This is because "to carry this burden, the employee must present substantial medical evidence." (Dubon v. World Restoration, (2104) (Dubon II) 79 Cal.Comp.Cases 1298, 1312, (Appeals Board en banc).) The RFA at issue seeks inpatient post-acute comprehensive rehabilitation for traumatic brain injury (TBI).
What proof carried it
The evidence the panel weighed, by kind.
PQME Dr. Richman's medical findings and equivocal deposition testimony regarding inpatient vs outpatient treatment.
From the decision · page 9(Exhibit 3, PDF page 26.) These findings are buttressed by PQME Dr. Richman who states: In summary, this is a 30-year-old male with a prior history of childhood epilepsy which had resolved and was lit up by an incident of 4/3/22 when the patient slipped and fall, sustaining traumatic induced epilepsy, with recurrent episodes ever since. This is distinctly different from posttraumatic epilepsy, which is related to damage to the brain from blunt head trauma, penetrating objects, intracranial bleeding, etc. The injury lit up his preexisting quiescent photogenic epilepsy. His current seizures are mixed and not optimally controlled.
RFA and Pre-Admission Evaluation Report documenting medical necessity of inpatient rehabilitation.
From the decision · page 8(Exhibit 3.) The relevant MTUS for traumatic brain injury recommends inpatient comprehensive integrated interdisciplinary rehabilitation when there are indications of "[s]ufficient residual symptoms and/or signs of mostly acute TBI to necessitate ongoing and daily treatment, be it medical, physical therapy, occupational therapy, or other." "Most patients will have incurred severe TBI, but occasionally, patients with moderate TBI may also be benefited by these programs." Frequency/Dose/Duration is listed as: "[h]ighly variable and depends on clinical status, including symptoms, signs, functional deficits, rate of progress, need for individualized care (e.g., coaching), etc." (Cal.
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