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WCAB: AME Reports Must Go to IMR

Hello, dear readers!

Is submitting an AME report, or a PQME report, to IMR required?  In the case of Garibay-Jimenez v. Santa Barbara Medical Foundation Clinic, the panel of WCAB commissioners answered: “Yes.”

Applicant sought to appeal a timely UR denial by submitting the issue to IMR.  Both parties had in their possession AME reports, but neither party sent them to IMR before the decision was made.  The WCAB, reversing the WCJ, ruled that Regulation 9792.10.5 and Labor Code section 4610.5(l)(1) require the defendant to provide AME reports to IMR for consideration.   “The error cited by applicant was the failure of both the UR and IMR physicians to review the reports of the AMEs who recommended the left ulnar nerve decompression and post-operative physical therapy.”

The WCAB held that relevant regulations impose a duty upon the employer (and its insurer) to provide relevant records to IMR, and when the defendant fails to do this, any adverse determination by IMR is subject to an appeal and, possibly, an IMR re-review at the employer’s expense.

Now, your humble blogger may not know the first thing about workers compensation, or about fancy cars, or big city doings, or even the new-fangled things the kids use like the twitter and the Instagram… but I do know what the word relevant means.  And, from what it looks like, an AME report (or reports)… well, relevant it’s not.

What opinions could an AME offer on the issue of medical necessity or the need for a particular course of treatment?  After all, compensability of the injury is not in question – the injury is already admitted.  Nor is the issue in dispute a total medical discharge.  The AMEs can’t offer much by way of necessity of medical treatment, after all, because Labor Code section 4062.2 specifically prescribes submitting to AMEs the issues reserved for UR and IMR.

So… what could the AME offer by way of “relevant” information? IMR can competently summarize records, and IMR is not concerned with matters of work restrictions, permanent disability, apportionment, etc.  The only relevant question is whether the treatment requested by the primary treating physician is medically necessary… and the good folks and UR and IMR are supposed to tackle that one themselves.

Now, you might say “Hey, Greg, the AMEs are the ones that recommended the treatment, so their opinion IS relevant.”  Well, if your humble blogger were sitting next to you when you said that, you would get the frowning of a life-time.  California Code of Regulations section 9785, tells us that the primary treating physician is “the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter.”  Furthermore, the same section tells us that the employee can have only one primary treating physician at a time.  So, while the AMEs can recommend treatment, the PTP is the one who is supposed review the recommendation and either concur or reject it.  And, whatever the PTP decides to do, his or her own report is the relevant one, not the original AME report.

So what is so “relevant” about AME reports?  Well, it looks like the WCAB considers the reports relevant, so defendants would be wise to provide AME and QME reports to IMR, even if the applicant has it in his or her possession.   What’s the downside to sending everything, out of fear of leaving out something that might be later considered “relevant”?

We get to suffer through accusations of flooding the IMR reviewer with irrelevant information in the hopes of hiding a needle in a haystack, as was the case when IMR was just rolling out.

Now, don’t get me wrong – the use of AMEs is a great thing.  It speeds up litigation process, it contains costs on panel disputes (which are now expected in almost every single case), and it provides an incentive for doctors to be reasonable and fair and to establish trust from both the defense and the applicant communities.  And, it doesn’t seem too far-fetched for the parties to trust an AME on the issue of medical treatment necessity.  But, if we’re not submitting the issue of medical treatment to the AME, and we are going the UR and IMR route, your humble blogger submits that medical-legal reports are not relevant.

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