Medical treatment, UR and IMR

What the Appeals Board did with this

Newest released decisions that turned on this issue. Each quotes the passage it turned on and links to the official PDF. Litigated tail — not a win rate, not a settlement value.

• ADJ15211632 · 2026-06-25 · San Diego District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.1Applicant seeks reconsideration of the April 14, 2026 Findings and Order (F&O), wherein the workers' compensation administrative law judge (WCJ) found that a prior utilization review (UR) decision denying authorization for a requested treatment barred a subsequent request for authorization (RFA) for the same treatment submitted on December 4, 2025. The WCJ further determined that the UR decision issued on December 8, 2025 regarding authorization for a wheelchair accessible hotel room was untimely but that the requested services were not medically necessary.

  The Appeals Board found that the WCJ erred in concluding the prior UR decision barred the subsequent request and that the December 8, 2025 UR decision was untimely but the requested treatment was medically necessary, warranting reconsideration.

  Official decision · page 1 →
• ADJ9600339 · 2026-06-22 · Los Angeles District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.1Applicant seeks reconsideration of the Findings and Order (F&O) issued on December 6, 2022, by the workers' compensation administrative law judge (WCJ). The WCJ found that applicant, while employed by defendant, sustained injury arising out of and occurring in the course of employment (AOE/COE)1 to various body parts; and that defendant did not deny medical treatment to applicant.

  The Board found that defendant's refusal to authorize treatment with Dr. Patterson, a physician employed by Casa Colina listed in the MPN, constituted an unreasonable denial of medical treatment under Labor Code section 4600 and related regulations and precedent cases Rivas and Montiel.

  Official decision · page 1 →
• ADJ17258260 · 2026-06-22 · San Francisco District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.1Defendant seeks reconsideration and/or removal of the "Findings of Fact and Orders" (F&O) issued on March 18, 2026, by the workers' compensation administrative law judge (WCJ). The WCJ found, in pertinent part, that additional qualified medical evaluator (QME) panels in psychology and internal medicine were warranted and ordered the Medical Unit to issue additional panels accordingly.

  The WCJ found good cause for additional panels in psychology and rheumatology, which the Appeals Board upheld, denying defendant's petition for reconsideration.

  Official decision · page 1 →
• ADJ12308686 · 2026-06-11 · Los Angeles District OfficeMedical treatment / UR / IMRdefendant prevailed

  Determinative passage · p.5In the present case, applicant designated Casa Colina rather than any individual physician as her primary treating physician. This designation violates AD Rule 9785(a)(1), which defines the primary treating physician as an actual physician and not a facility or other entity.

  Applicant designated a facility, not an individual physician, as primary treating physician, contrary to regulations; defendant provided access to three neurologists within the MPN, meeting statutory and regulatory requirements for access to care; applicant did not meet burden to show neglect or refusal to provide care.

  Official decision · page 5 →
• ADJ14305554 · 2026-06-09 · Santa Rosa District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.4II Section 4600(b) provides that "medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27." (Lab. Code, § 4600(b).) Section 5307.27 specifies that these guidelines refer to the Medical Treatment Utilization Schedule (MTUS). (Lab. Code, § 5307.27(a).) The MTUS can be found in AD Rules 9792.20 through 9792.27.23 (Cal. Code Regs., tit. 8, § 9792.20-9792.27.23). The MTUS is presumptively correct on the extent and scope of treatment and is the primary source of guidance for physicians. (Lab. Code, § 4604.5(a); Cal. Code Regs., tit. 8, § 9792.21(c).) However, the MTUS may be rebutted, and treatment may be warranted based on recommendations outside the MTUS in limited situations. (Cal. Code Regs., tit. 8, § 9792.21(d); see also Lab. Code, § 4604.5(d).) If a UR decision is untimely, the determination of medical necessity must be made by the WCAB based on substantial medical evidence consistent with the MTUS. (Dubon II, supra, 79 Cal.Comp.Cases at 1300.)

  The Appeals Board found the December 3, 2024 UR determination was untimely under Labor Code section 4610 and former AD Rule 9792.9.1(f), requiring further development of the record with current medical evidence to determine medical necessity. The WCJ erred in dismissing the request as untimely without considering applicant's medical evidence.

  Official decision · page 4 →
• ADJ118647 · 2026-06-08 · San Diego District OfficeMedical treatment / UR / IMRdefendant prevailed

  Determinative passage · p.9Applicant referenced some documents in her Petition for Reconsideration that she believed showed that she needed a service dog on a medical basis for her industrial injury. One document was identified on page 7 of the Petition for Reconsideration as a "2011 PTP order for a service dog" (Applicant's Exhibit 65, page 44). This document appears to be a prescription from Coast Pain Management with an illegible date. It stated "Pt requires service dog due to the applicant having significant functional limitations." After reviewing all the evidence, the Workers' Compensation Administrative Law Judge "WCJ" noted that there was no Request for Authorization form or RFAs in the exhibits by a treating physician requesting that Applicant be provided with a service dog for her industrial injury. There was no medical report in evidence that constituted substantial medical evidence that outlined why a service dog would be needed on an industrial medical basis for Applicant's bilateral shoulder and neck injury. For the above reasons, Applicant did not meet her burden of showing that her service dogs were needed on a medical basis for her industrial injury to her neck and bilateral shoulders.

  Applicant did not provide substantial medical evidence or a Request for Authorization from a treating physician to show that a service dog was reasonable and necessary medical treatment for her industrial injury.

  Official decision · page 9 →
• ADJ10966476 · 2026-05-29 · Los Angeles District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.8performed any investigation into the need for home health care services during that period. Therefore, the record confirms the need for home health care services during the period July 4, 2018 to October 17, 2019. We also conclude that the evidentiary record supports the reasonableness of the services in accordance with the medical treatment utilization schedule for home health care services.

  The WCAB found that the widow was entitled to reimbursement for home health care services from July 4, 2018 to October 17, 2019 based on medical prescriptions and defendant's failure to investigate the need for such care, consistent with Labor Code and case law requirements.

  Official decision · page 8 →
• ADJ8710590 · 2026-05-26 · Riverside District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.12FINDINGS OF FACT 1. Cost petitioner met its burden of proof under Labor Code section 4620 to show a contested claim existed at the time it provided its medical-legal services beginning on February 5, 2013, and that the services were reasonable and necessary at the time the costs were incurred pursuant to Labor Code sections 4620 and 4621. 2. Cost petitioner is entitled to be reimbursed for the reasonable value of its services and penalties and interest pursuant to Labor Code section 4622. The issue of the amount of payment is deferred. 3. Defendant did not meet its burden to show that it issued timely and compliant objections or Explanations of Review in response to cost petitioner's invoices. 4. The provisions of Labor Code section 4055.2, including the failure to serve a copy of the subpoena, did not render the subpoenas invalid.

  Cost petitioner met burden to show contested claim existed when services were provided and services were reasonable and necessary; defendant failed to issue timely and compliant objections or Explanations of Review; cost petitioner entitled to reimbursement, penalties, and interest; amount deferred to trial level.

  Official decision · page 12 →