Utilization Review Case Decided By WCAB

The applicant had an industrial injury on October 22, 2003. The applicant was treated by his treating doctor who referred the applicant to two other doctors for surgical consultation.

These doctors determined that the applicant needed two MRI’s. The request for the MRI’s were served on defendant. The defendant took longer than 14 days to object to the necessity for the MRI’s.

The case proceeded to an expedited hearing. At the hearing the Workers’ compensation Judge (WCJ) indicated that the MRI’s should be provided and excluded the defendant’s utilization review report because it was untimely pursuant to Labor Code section 4610 (g) (1).

Defendants filed a petition for reconsideration. The case was heard by the entire Workers’ Compensation Appeals Board (WCAB) who issued this en banc decision.

The WCAB found that the utilization review time deadlines of section 4610 are mandatory. If the defendant misses these deadlines the defendant is then precluded from using the utilization review process for the medical treatment in question.

If the defendant obtains a utilization review report outside of the time frames the report will not be admissible. In addition the report can not be forwarded to an AME or QME. The WCAB indicated this would be an attempt to get the report in the back door.

However, if the defendant does not meet the time lines of 4610 (g) (1) the defendant can still use the procedure established under Labor Code section 4062 (a). You must still meet the timelines established under section 4062 (a) or this report will not be admissible either. Thus, as protection it may be good form to object if you are not certain your utilization review doctor can issue a report timely.

Case: Sandhagen v. Cox & Cox
This is a en banc decision by the WCAB

Harvey Brown
3501 Jamboree Rd. Suite 602
Newport Beach, CA 92660

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