Second Applicant UR/IMR Constitutional Challenge Fails


Sacramento, CA - Daniel Ramirez sustained an injury to his lower leg and ankle in the course of his job as an office assistant for the State Department of Health Care Services. The claims were administered by the State Compensation Insurance Fund. 

Ramirez settled his case by stipulations providing him with further medical treatment for the injury. The treatment included a gym/swim membership, and, over the course of about one and a half years. 

His physician prescribed another 12 sessions of acupuncture. The utilization review recommended that the requested treatment be denied. Ramirez appealed the utilization review denial under the independent medical review process. IMR upheld the UR decision.

Ramirez appealed the decision of the independent medical review to the Board. The grounds for the appeal were that the independent medical reviewer "may have been subject to a material conflict of interest that is in violation of Section 139.5," and the "determination may have been the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability." 

Ramirez wanted discovery to determine whether the doctor performing the independent medical review was biased or had a conflict of interest. He also raised constitutional violations regarding the UR/IMR process which were beyond the jurisdiction of the WCAB. The appeal was taken off calendar pending resolution of the constitutional issues. 

Ramirez filed a petition for writ of review with the Court of Appeal. His constitutional challenges were rejected in the published case of Ramirez v WCAB.

The Court concluded that the Board had no jurisdiction to review a utilization review that was alleged to be defective for failure to follow the medical treatment utilization schedule. Whether the utilization review followed the medical treatment utilization schedule is directly related to a determination of medical necessity. By statute, a review of a determination of medical necessity is limited to the medical professionals performing the independent medical review.

On the constitutional challenges, the Court affirmed the prior decision of Stevens v. Workers’ Comp. Appeals Bd. (2015) 241 Cal.App.4th 1074 on these issues. Stevens concluded that California’s process for reviewing workers’ medical requests did not violate due process by failing to provide notice and a meaningful opportunity to be heard. Stevens also considered an argument made here that the independent medical review process violates due process because the reviewer is anonymous. The Court agreed with Stevens that "the process in its entirety provides sufficient due process protections."



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