What the panel ordered
The Petition for Reconsideration filed by Defendant was denied.
Defendant filed a Petition for Reconsideration of the Findings of Fact and Order issued on April 27, 2022, which was denied by the WCAB panel on July 5, 2022.
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 WCJ and panel found that the left L3,4 TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary based on medical reports from Dr. Rho and other providers demonstrating the treatment was required to cure or relieve the injured worker's condition.
From the decision · page 6Turning to defendant's contention that the WCJ erroneously determined that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary, we agree with the WCJ's reasoning, as stated in the Report, that the medical reports from Dr. Rho, Casa Colina, and Learning Services Home and Community demonstrate that the treatment sought by the June 9, 20201 RFA is reasonably required to cure or relieve the injured worker from the effects of his injury. Accordingly, we are unable to discern error in the WCJ's finding that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary.
The WCJ and the panel found that the Utilization Review (UR) determinations of Dr. Patterson's May 17, 2021 RFA were untimely because the UR decisions were not timely communicated to the applicant or the applicant's primary treating physician as required by Labor Code section 4610, supported by evidence including emails and letters from applicant's counsel showing lack of receipt of UR denials.
From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The UR determinations of Dr. Patterson's May 17, 2021 RFA were not timely communicated to applicant or applicant's PTP as required by Labor Code section 4610.
Favours Applicant prevailed
This lack of timely communication rendered the UR determinations untimely, allowing the WCAB to determine medical necessity, favoring the applicant.
From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...
Medical reports from Dr. Rho and other providers demonstrated the left L3,4 TFE injection was reasonably required to cure or relieve the injured worker's condition.
Favours Applicant prevailed
This supported the WCJ's finding that the treatment was reasonable and necessary, favoring the applicant.
From the decision · page 6Turning to defendant's contention that the WCJ erroneously determined that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary, we agree with the WCJ's reasoning, as stated in the Report, that the medical reports from Dr. Rho, Casa Colina, and Learning Services Home and Community demonstrate that the treatment sought by the June 9, 20201 RFA is reasonably required to cure or relieve the injured worker from the effects of his injury. Accordingly, we are unable to discern error in the WCJ's finding that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary.
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. Rho's June 9, 2021 RFA for left L3,4 TFE injection was found reasonable and necessary based on medical reports.
The WCJ and panel relied on medical reports from Dr. Rho and other providers to find the treatment reasonable and necessary.
From the decision · page 6Turning to defendant's contention that the WCJ erroneously determined that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary, we agree with the WCJ's reasoning, as stated in the Report, that the medical reports from Dr. Rho, Casa Colina, and Learning Services Home and Community demonstrate that the treatment sought by the June 9, 20201 RFA is reasonably required to cure or relieve the injured worker from the effects of his injury. Accordingly, we are unable to discern error in the WCJ's finding that the left L 3, 4, TFE injection requested by Dr. Rho's June 9, 2021 RFA was reasonable and necessary.
Dr. Patterson's May 17, 2021 RFA was the subject of a Utilization Review determination found untimely due to lack of timely communication as required by Labor Code section 4610.
The WCJ and panel relied on the lack of timely communication of the UR determination related to Dr. Patterson's RFA to find the UR untimely.
From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610
Labor Code section 4610 requires timely communication of Utilization Review decisions to the requesting physician and injured worker or their attorney.
The WCJ and panel applied this standard to find the UR determinations untimely due to lack of timely communication.
From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...
Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519
A UR decision that is timely made but not timely communicated is untimely and the Appeals Board has jurisdiction to determine medical necessity.
The panel applied this precedent to support the finding that the UR determinations were untimely due to lack of timely communication.
From the decision · page 3This WCJ accepts that the proofs of service regarding the UR denials, with the exception of one, do appear to have been mailed to applicant's counsel. However, that does not meet the requirement of Labor Code section 4610.... [A] UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests... " (Sandhagen, supra, 44 Cal. 4th at p. 241.). Thus, section 4610... imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed...
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
The Appeals Board has jurisdiction to determine whether a UR decision is timely and if untimely, may determine medical necessity.
The panel applied this en banc precedent to confirm jurisdiction over untimely UR determinations.
From the decision · page 4Section 4610 provides time limits within which a UR decision must be made by the employer. (§ 4610 et seq.) These time limits are mandatory. In 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 a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) 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.)
Labor Code section 4600(a)
Labor Code section 4600(a) requires employers to provide reasonable medical treatment to cure or relieve effects of industrial injury.
The panel applied this standard to find the left L3,4 TFE injection reasonable and necessary.
From the decision · page 4Labor Code section 46001 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (§ 4600(a).) Employers are required to establish a UR process for treatment requests received from physicians. (§ 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.)
What proof carried it
The evidence the panel weighed, by kind.
Emails and letters from applicant's counsel showing lack of receipt of UR denials
From the decision · page 3While Defendant argues that there is no evidence offered by Applicant that these denials were not timely received, that is not accurate. Applicant offered a series of emails and letters to Defendant advising that they had not received any UR denials. Applicant's Exhibits 1 through 3 all speak to that issue. Defendant offers no comment as to the evidentiary value of those documents that do rebut the claim that the UR denials were received by Applicant's counsel and Dr. Patterson. There was no testimony provided by either side as the matter submitted on the record. The WCJ may rely on the evidence admitted and draw inferences from that evidence which form the WCJ' s opinion and beliefs as to the weight and credibility of the evidence offered. Here, the WCJ, after reviewing a series of letters from Applicant's counsel to the Defendant informing them that they did not have copies of any UR denials, reached a reasonably supported conclusion that they had not been communicated in accordance with Labor Code Section 4610. This conclusion is not rebutted by Defendant's indication that they were served in the course of the regular mail.... The series of emails to and from the parties reflect that Applicant's counsel engaged in ongoing attempts to obtain copies of the UR denials from the Defendant. Yet, it
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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