WCDefenseCA

Happy Monday, dear readers!

Have you had enough blog posts about Utilization Review yet? What? WHAT?!? Ok, calm down – we’ve gone over this before… I can’t actually hear you screaming into your computer screen, so I’m going to assume that you haven’t had enough UR posts yet and you’re just dying for more!

Submitted for your consideration is the case of Wells v. Seltzer, Fontaine, Beckwith.  The skinny on the facts is that applicant sought to use her future medical award as part of the stipulated award from the CT claim.  Her Primary Treating Physician (what the cool kids in comp refer to as the “PTP”) submitted an RFA for various drugs on March 26, 2015, and the RFA was referred to UR, which requested additional information on April 2, 2015 (for the folks keeping score at home, that’s 5 working days or 7 actual days later).

On April 7, the RFA was denied pending receipt of the additional information requested.  (Again, folks, that’s 8 working days and 12 actual days).  Now comes the crazy fact that makes this so interesting: the request for additional information was not signed by the UR physician!

At an expedited hearing, applicant argued that Labor Code section 4610(e) holds that “only a licensed physician” can modify, delay, or deny requests for authorization of medical treatment.  Defendant’s response was to cite section 9792.9.1(f) of the California Code of Regulations, allows non-physician reviewers to delay making a determination to get additional information (see subsection (f)(1)(A) and (f)(2)(A)).

The WCJ adopted applicant’s position and held that a delay notice must be signed by a physician.

On reconsideration, the WCAB rejected the WCJ’s position, noting that the Labor Code’s requirement for delays to be made by physicians is only when there is actually a decision to modify, delay, or deny a request, which is distinct from simply requesting more information.

Applicant’s petition for review by the Court of Appeal was denied.

If any of this sounds familiar, it should – the facts are almost identical to those of Newton v. Jack-in-the-Box.  So, in defense of UR denials based on unanswered requests for additional information, defendants now have to panel cases upon which to rely.

Small miracles, dear readers – take them as they come!