What the panel ordered
Reconsideration granted to amend the finding regarding Utilization Review; underlying denial of ongoing transportation benefits affirmed.
Applicant sought reconsideration of the July 26, 2023 Findings and Order denying ongoing transportation to medical appointments; WCAB granted reconsideration to amend the finding regarding Utilization Review but affirmed the denial of broader transportation benefits.
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 RFAs in evidence requested transportation for a single appointment, not ongoing transportation to all appointments; no timely Utilization Review was performed, so WCAB had jurisdiction, but the record did not support a broader award.
From the decision · page 6However, as the WCJ explains in Finding of Fact No. 8, neither the October 22, 2021 nor November 23, 2021 RFAs request that defendant authorize medical transportation to all medical appointments on all appointment dates. Rather, the November 23, 2021 RFA reiterates the request lodged in the October 22, 2021 RFA for transportation to a single October 29, 2021 appointment with Dr. McWhorter. (Ex. 2, Request for Authorization, November 23, 2021; Ex. 7, Request for Authorization, October 22, 2021.) While applicant urges a broader reading of the RFA in tandem with the November 4, 2021 and April 23, 2023 letters of Dr. McWhorter, we agree that on the record before us, the requests were limited to a single date of service. (Opinion on Decision, p. 4.) Accordingly, we discern no basis to disturb the WCJ's determinations in this regard.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The RFAs submitted by Dr. McWhorter requested transportation for a single appointment, not for all appointments.
Favours Defendant prevailed
Limited the scope of the benefit that could be awarded; no evidence supported ongoing transportation.
From the decision · page 6However, as the WCJ explains in Finding of Fact No. 8, neither the October 22, 2021 nor November 23, 2021 RFAs request that defendant authorize medical transportation to all medical appointments on all appointment dates. Rather, the November 23, 2021 RFA reiterates the request lodged in the October 22, 2021 RFA for transportation to a single October 29, 2021 appointment with Dr. McWhorter. (Ex. 2, Request for Authorization, November 23, 2021; Ex. 7, Request for Authorization, October 22, 2021.) While applicant urges a broader reading of the RFA in tandem with the November 4, 2021 and April 23, 2023 letters of Dr. McWhorter, we agree that on the record before us, the requests were limited to a single date of service. (Opinion on Decision, p. 4.) Accordingly, we discern no basis to disturb the WCJ's determinations in this regard.
Defendant declined to perform Utilization Review, so WCAB had jurisdiction to determine medical necessity.
Favours neutral
Allowed the WCAB to decide the issue rather than IMR, but did not change the outcome due to the limited scope of the RFAs.
From the decision · page 6Accordingly, there is no timely UR decision that is otherwise subject to IMR, and the WCAB has jurisdiction to determine the medical necessity of the request. (Dubon II, supra, at p. 1312.)
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.
Dr. McWhorter issued RFAs and reports supporting the need for transportation to a specific medical appointment, but did not request ongoing transportation to all appointments.
The WCAB found that Dr. McWhorter's RFAs and reports substantiated the need for transportation only for a single appointment, not for all appointments.
From the decision · page 6However, as the WCJ explains in Finding of Fact No. 8, neither the October 22, 2021 nor November 23, 2021 RFAs request that defendant authorize medical transportation to all medical appointments on all appointment dates. Rather, the November 23, 2021 RFA reiterates the request lodged in the October 22, 2021 RFA for transportation to a single October 29, 2021 appointment with Dr. McWhorter. (Ex. 2, Request for Authorization, November 23, 2021; Ex. 7, Request for Authorization, October 22, 2021.) While applicant urges a broader reading of the RFA in tandem with the November 4, 2021 and April 23, 2023 letters of Dr. McWhorter, we agree that on the record before us, the requests were limited to a single date of service. (Opinion on Decision, p. 4.) Accordingly, we discern no basis to disturb the WCJ's determinations in this regard.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code, § 4600
Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury.
Applied to determine whether transportation to medical appointments is a covered benefit.
From the decision · page 4The issue presented herein involves the question of whether transportation to and from medical appointments is medically necessary. Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).) Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal. 4th 230, 236, 79 Cal. Rptr. 3d 171, 186 P.3d 535.)
Lab. Code, § 4610
Employers are required to establish a UR process for treatment requests received from physicians.
Applied to determine whether the defendant's denial was a valid UR decision.
From the decision · page 4The issue presented herein involves the question of whether transportation to and from medical appointments is medically necessary. Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).) Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal. 4th 230, 236, 79 Cal. Rptr. 3d 171, 186 P.3d 535.)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
Where there is no timely UR decision subject to IMR, the issue of medical necessity must be determined by the WCAB.
Applied to find WCAB jurisdiction over the medical necessity dispute due to lack of timely UR.
From the decision · page 5In 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 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.) As noted in the Dubon II decision, 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." (Id. at p. 1305, emphasis in original.) Sections 4610 and 4610.5 expressly define a UR decision addressing treatment "based in whole or in part on medical necessity." In Dubon II, the Appeals Board found that sections 4610.5 and 4610.6 "specifically provide that where there is a dispute regarding a UR decision on `medical necessity,' the dispute shall be resolved only by IMR." (Id. at p. 1309.) However, "where there is no timely UR decision subject to IMR, the issue of medical necessity must be determined by the WCAB." (Id. at p. 1312.)
Avalon Bay Foods v. Workers' Comp. Appeals Bd. (Moore) (1998) 18 Cal. 4th 1165
Expenses for transportation to and from medical treatment appointments are ancillary to medical treatment benefits under section 4600.
Applied to confirm that transportation is a covered ancillary benefit when medically necessary.
What proof carried it
The evidence the panel weighed, by kind.
The RFAs and narrative reports from Dr. McWhorter were limited to a single appointment and did not request ongoing transportation.
From the decision · page 6However, as the WCJ explains in Finding of Fact No. 8, neither the October 22, 2021 nor November 23, 2021 RFAs request that defendant authorize medical transportation to all medical appointments on all appointment dates. Rather, the November 23, 2021 RFA reiterates the request lodged in the October 22, 2021 RFA for transportation to a single October 29, 2021 appointment with Dr. McWhorter. (Ex. 2, Request for Authorization, November 23, 2021; Ex. 7, Request for Authorization, October 22, 2021.) While applicant urges a broader reading of the RFA in tandem with the November 4, 2021 and April 23, 2023 letters of Dr. McWhorter, we agree that on the record before us, the requests were limited to a single date of service. (Opinion on Decision, p. 4.) Accordingly, we discern no basis to disturb the WCJ's determinations in this regard.
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