WCDefenseCA

Utilization Review, as previously discussed here and here, is an effective tool in filtering out unnecessary treatment.  However, Labor Code § 4610 has its own requirements to make Utilization Review reports valid, including deadlines and qualifications for reviewing physicians.

If a denial of medical treatment is based on UR, and the UR report does not comply with § 4610, can the denial give rise to sanctions?

Labor Code § 5813 provides that sanctions may be imposed “as a result of bad-faith actions or tactics that are frivolous or solely intended to cause unnecessary delay.”

Recently, an applicant took this issue up on appeal, finding no sympathy from the Workers’ Compensation Judge, the Workers’ Compensation Appeals Board or, ultimately, the Court of Appeal (Dominguez v. Workers’ Compensation Appeals Board).

There, the applicant claimed that defendant’s denial of dermatologic treatments based on a UR report was sanctionable conduct because the UR report was not timely and was prepared by an anesthesiologist, rather than a dermatologist or an orthopedist (the underlying industrial injury was an orthopedic one).

The WCJ and the WCAB both found that applicant’s contentions regarding the validity of the UR report were without merit.  But, even if applicant was correct on both counts, the denial does not rise to the level of § 5813 sanctions.  The applicant kept saying sanctions, and the courts responded with…

In other words, go with your gut, and stick to the UR report – at the most, you’ll end up paying the treatment, but no sanctions should be forthcoming.