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WCAB: Future Medical of Any Kind Entitles Applicant to Change PTPs

Hello, dear readers!  Welcome back from your weekend!  Your humble blogger brings you yet another panel decision touching on the topic of… you guessed it! Utilization Review!

The case is that of Samaras v. Deluxe Laboratories (that’s pronounced “lab-or-a-tories”… or at least it should be).  Applicant sustained an admitted injury to his neck and back in 2008, and claimed several additional body parts as well.  In 2009, he was declared permanent and stationary by his then-primary-treating physician, but then selected a new PTP in 2014 (with the guidance of counsel).

When the new PTP requested authorization for treatment, defendant reasoned that there can’t be a change in PTPs after there has been a discharge.  A new PTP can only be designated after a PQME has declared that there is a need for further medical treatment.  The WCJ adopted this reasoning (authority to this effect and commentary on the law on this was discussed previously on this humblest of blogs).

The discharge in the Samaras case was based on the original PTP’s finding that applicant was discharged from “active care.”  However, in reversing the WCJ’s reliance on such a discharge to confine further litigation to the panel process, the WCAB noted a distinction between a total discharge and the Samaras discharge, wherein the P&S report provided for oral anti-inflammatory or non-narcotic analgesic medications.

Based on the WCAB’s reasoning in the Samaras case, the provision of ANY future medical care, even maintenance care – even Tylenol, applicant would be entitled to change primary treating physicians instead of using the panel system.  California Code of Regulations 9785 defines “released from care” as a “determination by the [PTP] that the employee’s condition has reached a permanent and stationary status with no need for continuing or future medical treatment.”   Furthermore, “continuing medical treatment” is defined as “treatment that is reasonably required to cure or relieve the employee from the effects of the injury.”

So, if the doctor determines that applicant needs breath-mints or Advil, applicant can continue to change treating physicians, and so possibly overturn his or her discharge.  And, so, if applicant can change PTPs, then the new PTP can request authorization for treatment, which defendant then must process through Utilization Review.

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