Authorities as the decision cited them, with how this panel applied each one.
California Labor Code section 4610(k)
California Labor Code section 4610(k) limits the 12-month period of effectiveness of a utilization review decision to the same physician or another physician within the same practice group for the same treatment.
The court applied this statute to determine that the defendant must conduct utilization review for the 9/3/2021 RFA by Dr. Abitbol because he is not in the same practice group as Dr. Smith.
From the decision · page 2Nevertheless, section 4610(k) limits the 12-month period of effectiveness of a UR decision
only "with regard to a further recommendation by the same physician, or another physician
within the requesting physician's practice group..." (Lab. Code, § 4610(k) emphasis added.)
Moreover, where statutory language in unambiguous, we are bound by the plain meaning of the
statute. (See Miklosy v. Regents of University of California (2008) 44 Cal.4th 876, 888.)
California Labor Code sections 4610(i)(1) and 4610(i)(3)
Utilization review decisions must be made within 5 business days, or within 72 hours if the employee's condition is an imminent and serious threat to health.
The court applied these statutes to find that the utilization review response to Dr. Abitbol's RFA was untimely and that expedited review was warranted due to the serious health threat.
From the decision · page 11A request for prospective or concurrent utilization review is to be made within 5 normal business
days from receipt of a request for authorization. (California Labor Code Section 4610 (i)(1)).
However, if "...the employee's condition is one in which the employee faces an imminent and
serious threat to the employee's health, including, but not limited to, the potential loss of life, limb,
or other bodily function, or the normal timeframe for the decision making process... would be
detrimental to the employee's life or health or could jeopardize the employee's ability to regain
maximum function, decisions to approved, modify, or deny requests by physicians prior to, or
concurrent with, the provision of medical treatment services to employees shall be made in a timely
fashion that is appropriate for the nature of the employee's condition, but not to exceed 72 hours
after the receipt of the information reasonably necessary to make the determination..." (California
Labor Code Section 4610 ((i)(3).)
California Labor Code section 5705
The burden of proof rests with the party holding the affirmative of the issue, and must be met by a preponderance of the evidence.
The court applied this standard to determine that the applicant failed to meet the burden of proof for the reasonableness and necessity of Zolgensma medication.
From the decision · page 12The burden of proof rests with the party holding the affirmative of the issue. (California Labor Code
section 5705). In that regard, applicant bears the burden of proof. "...The Legislature amended
section 3202.5 to underscore that all parties, including injured workers, must meet the evidentiary
burden of proof on all issues by a preponderance of the evidence. Accordingly, notwithstanding