What this form is for
Independent medical review application * For injured workers who need to get an independent medical review
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- 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 →