A unanimous WCAB panel has held that when objecting to a Utilization Review (UR) non-certification of treatment, the employee must first engage in the Labor Code section 4062 AME/QME process before proceeding to an Expedited Hearing. Willis v. Waste Management/ACE America Ins. Co.
As previously reported on this blog, a WCAB panel was split on this question in Corona v. Church Mutual Ins. Co. In Corona, the applicant’s primary treating physician had prescribed radiofrequency ablation which was non-certified by the defendant’s UR physician. Rather than timely objecting to that determination under Labor Code section 4062 and seeking the opinion of an AME or panel QME to resolve the dispute, the applicant instead filed a Declaration of Readiness to Proceed to an Expedited Hearing. The trial judge awarded the treatment.
On reconsideration, a divided WCAB panel affirmed the judge’s award. The real question was whether the state Supreme Court’s 2008 decision in Sandhagen permitted the employee to go directly to a hearing on a UR non-certification issue without first proceeding under 4062. The majority opined that the employee may choose either to engage in the AME/QME process first or elect to instead to go directly to the Board (which comes in handy if the employee misses a deadline in the 4062 process).
The dissenting Commissioner found that the 4062 process was mandatory for both parties before proceeding to a hearing. This assures that the medical dispute is addressed by a medical-legal evaluator and resolved based upon substantial medical evidence.
The combined holding of Willis and the Corona dissent seem to establish that from now on, objections to Utilization Review (UR) non-certifications must go though the Labor Code section 4062 AME/QME process before proceeding to an Expedited Hearing.