Independent Medical Reviews, Utilization Review, WCAB, Workers' Compensation, Yrulegui & Roberts

Utilization Review in California Workers’ Compensation: When Can a Judge Address Medical Necessity?

Posted on by Joseph Yrulegui

Introduction

In California’s workers’ compensation system, utilization review (UR) is the primary “gatekeeper” to determine whether requested medical treatment is medically necessary. If UR is performed timely and in compliance with statutory and regulatory requirements, a Workers’ Compensation Judge (WCJ) generally cannot second-guess or overturn the treatment determination. Instead, disputes go to Independent Medical Review (IMR).

But what happens if UR is late, procedurally defective, or never completed? In those situations, the WCJ may regain authority to decide the issue of medical necessity. Below is an overview of how UR works, when a judge can (and cannot) intervene, and how expedited review fits into the process.

1. Statutory Basis for Utilization Review

Labor Code § 4610

  • Sets Out UR Requirements
    This statute outlines the requirement that all employers or their claims administrators establish a utilization review process.
  • Timelines
    • Prospective UR: Must be completed within 5 working days (extendable to 14 days) of receiving a Request for Authorization (RFA).
    • Concurrent UR: Usually within 72 hours if an ongoing course of treatment is at issue.
    • Retrospective UR: For treatment already provided, determination must be made within 30 days of receiving necessary information.
  • Procedural Requirements
    Employers/claims administrators must ensure they provide proper notices, use qualified medical professionals for decisions, and follow evidence-based medicine guidelines (such as the Medical Treatment Utilization Schedule, or MTUS).

Labor Code §§ 4610.5 & 4610.6 (IMR)

  • Once UR issues a timely and valid denial, modification, or delay of treatment, the injured worker (or provider) may request an Independent Medical Review (IMR).
  • IMR decisions are generally final and binding, absent certain narrow exceptions (fraud, conflict of interest, etc.).

2. The Judge’s Role in Medical Necessity

The primary rule: If UR is timely and procedurally valid, the WCJ does not have jurisdiction over the question of whether treatment is medically necessary. Medical necessity disputes must be resolved through IMR.

However, if UR is untimely or procedurally defective, a WCJ may decide the treatment dispute. The key cases here include:

  • Dubon v. World Restoration, Inc. (“Dubon I & II”): The Appeals Board clarified that if UR is invalid only because of timing or material procedural defects, the WCJ may address medical necessity.
  • Bodie v. BHHC: Reiterates that the WCJ’s authority to decide medical necessity applies if there is a failure to issue a timely/valid UR decision.

Common Procedural Defects

  • Missing deadlines.
  • Failure to use the correct notice format.
  • No physician review for modifications/denials.

In each of these scenarios, the defense effectively loses the “UR shield,” and medical necessity becomes a litigated issue before the WCJ.

3. Expedited Review

Expedited review is required when the injured worker faces an imminent and serious threat to health, including severe pain or risk of a medical emergency. The regulations provide that a utilization review decision in an urgent or emergency scenario must be made as soon as possible based on the injured worker’s medical needs, but not to exceed 72 hours from receipt of the request.

  • Applicable Regulations:
    • 8 CCR 9792.9.1(c)(4) – Requires expedited decisions when “the injured worker’s condition is such that the injured worker faces an imminent and serious threat to his or her health, including but not limited to the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision making process would be detrimental to the injured worker’s life or health or could jeopardize the injured worker’s permanent ability to regain maximum function.”

Failure to issue an expedited decision within the mandated time can render the UR determination invalid, again opening the door for a WCJ to determine medical necessity.

4. When Does a Judge Address Medical Necessity?

Summarizing:

  1. Timely, Valid UR
    • The judge cannot determine medical necessity.
    • Any dispute heads to IMR.
  2. Late or Defective UR
    • The judge may decide medical necessity.
    • The injured worker or physician can present evidence (reports, expert opinions, treatment guidelines). The defense can do the same. The WCJ then decides.
  3. No UR
    • If the defense fails to conduct UR at all, the judge again regains authority to assess medical necessity directly.
  4. Expedited/Immediate Need
    • If UR fails to address an expedited request within 72 hours, that determination is arguably untimely, allowing the WCJ to decide.

5. Practical Tips for Claims Adjusters and Employers

  1. Know Your Timelines
    • Track the 5-working-day window for prospective UR and the 72-hour deadline for expedited requests.
    • Diary these deadlines as soon as you receive a valid RFA.
  2. Ensure Procedural Compliance
    • Use the correct forms and notices, and have a qualified physician issue any denials or modifications.
    • Defenses can unravel quickly if the UR decision lacks required signatures or the correct level of medical reviewer.
  3. Communicate & Document
    • Maintain open channels with the requesting physician. If additional information is needed, request it promptly, in writing, and document everything.
    • A well-documented paper trail can support you if there is a challenge to UR’s timeliness or sufficiency.
  4. Expedited Handling Where Appropriate
    • If a worker’s physician claims urgent need, confirm the medical basis. If the request truly requires expedited review, process accordingly.
    • Delays or confusion in triaging urgent requests can lead to invalid UR and cede the medical necessity question to the WCJ.
  5. Prepare for IMR
    • If a denial or modification occurs via timely UR, an injured worker may request IMR. Ensure that evidence-based guidelines, especially the MTUS, support your UR decision.
    • A well-supported UR determination is more likely to be upheld during IMR.

Conclusion

Utilization review remains a cornerstone of California workers’ compensation, designed to ensure that only medically necessary care is authorized. A valid and timely UR determination channels disputes into Independent Medical Review, effectively keeping the question of medical necessity out of the WCAB courtroom. However, any slip in timeliness or procedure can forfeit that advantage, leaving a Workers’ Compensation Judge to decide whether requested treatment is warranted.

For claims adjusters and employers, the lesson is clear: UR compliance is crucial. Stay mindful of deadlines (especially for expedited requests), adhere to notice requirements, and ensure decisions are physician-reviewed and evidence-based. Doing so protects you from costly litigation over treatment and preserves the UR/IMR process for resolving disputes.

Questions?
If you need guidance on UR workflows, expedited review protocols, or how to ensure your UR determinations withstand scrutiny, Yrulegui & Roberts is here to help. We represent and advise California employers, carriers, and claims administrators in all aspects of workers’ compensation defense—reach out today!

Joseph Yrulegui