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.