Calif. Court Clarifies Steps for Disputing Utilization Review Decisions

Case File

A California court made clear that irrespective of the reasons why a treating physician selects a particular duration of treatment in a request for authorization, the request is subject to utilization reviews and to independent medical review after that, and nothing in the statute prohibits an employer from seeking utilization review of subsequent requests for more of the same medical treatment. Simply Research subscribers have access to the full text of the decision.

Case

Illinois Midwest Ins. Agency, LLC v. Rodriguez, No. B344044 (Cal. Ct. App. 11/10/25)

What Happened?

A mechanic sustained significant head and brain injuries while working for a California employer. The employer's insurer admitted that the mechanic's injuries were industrial, arising out of and occurring in the course of his employment.

The mechanic's doctor began requesting that the mechanic receive home health services in six-week increments, and the carrier approved at least eight requests for authorization of home health care.

While a claims adjuster approved some of the request, the carrier authorized several others only after sending them to utilization review.

Workers' Comp 101: Utilization review is a statutorily mandated workers' compensation procedure in which medical professionals determine the medical necessity of a requested medical treatment when an employer objects to the request.

When a utilization review physician denied a request for authorization, the mechanic sought a hearing before a workers' compensation judge. The WCJ found that the mechanic was entitled to the ongoing home health services. According to the WCJ, because the evidence established that the mechanic had an "ongoing and constant need for home health care," the carrier could not terminate treatment without a showing of substantive medical evidence that there was a change in the mechanic's condition.

The carrier appealed to the Workers' Compensation Appeals Board, which upheld the WCJ's ruling and determined that the mechanic's home health care services were medically necessary. As a result, any change to the established need for medical treatment would necessarily involve a change in the mechanic's condition or circumstance such that a renewed review of the medical necessity of the requested treatment was appropriate and indicated.

The carrier appealed to court.

Rule of Law

California law provides that an employer is responsible for providing an injured worker with medical treatment or related care that is reasonably requited to cure or relieve the effects of the injury.

Under California's utilization review process, a claims administrator may approve medical treatment, but only a medical expert is authorized to modify, delay, or deny a physician's request for authorization of treatment.

When the utilization review decision modifies, delays, or denies a request for authorization of treatment, independent medical review is generally the only way for the worker to obtain review of the decision.

Workers' Comp 101: In California, independent medical review is limited to an examination of the medical necessity of the disputed medical treatment. The review is performed by an independent organization using medical professionals to perform the review. Independent medical review organizations are under contract with the administrative director of the Division of Workers' Compensation. The organizations must be independent of any workers' compensation insurer or workers' compensation claims administrator doing business in California. The medical professionals performing the review must be licensed physicians knowledgeable in the treatment of the employee's medical condition.

What the Court Said

According to the court, the WCAB did not have jurisdiction to resolve a dispute about the medical necessity of home health care services for the mechanic because an independent medical review is the only means of review or appeal of a utilization review decision.

"The duration of treatment is determined, authorized, and reviewed consistent with the [medical treatment utilization schedule, known as MTUS], and the employee continues to bear the burden of proving that the medical treatment is reasonable and necessary," the court wrote.

Verdict: The court annulled the WCAB's decision and remanded the case to the board.

Takeaway

In California, there is no exception to the statutorily mandated dispute resolution procedures for ongoing or continuing treatment; when a request for authorization of treatment is submitted and there is a dispute over whether the request treatment is medically necessary, the dispute must be resolved through the utilization review process, rather than in an extra-statutory proceeding before the WCAB.

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