Appeals Board Limits Applicability of Independent Medical Review

The Appeals Board has issued an en banc decision addressing the WCAB’s jurisdiction to resolve medical disputes and the applicability of Independent Medical Review. In Jose Dubon v. World Restoration, Inc.; and State Compensation Insurance Fund, the Appeals Board held as follows:
1. IMR solely resolves disputes over the medical necessity of treatment requests. Issues of timeliness and compliance with statutes and regulations governing UR are legal disputes within the jurisdiction of the WCAB.
2. A UR decision is invalid if it is untimely or suffers from material procedural defects that undermine the integrity of the UR decision. Minor technical or immaterial defects are insufficient to invalidate a defendant’s UR determination.
3. If a defendant’s UR is found invalid, the issue of medical necessity is not subject to IMR but is to be determined by the WCAB based on substantial medical evidence, with the employee having the burden of proving the treatment is reasonably required.
4. If there is a timely and valid UR, the issue of medical necessity shall be resolved through the IMR process if requested by the employee.
In the case at bar, the primary treating physician and AME had recommended spinal surgery following the failure of conservative care. UR denied the request for surgery following review of the Request for Authorization and approximately 18 pages of medical records. UR did not review the voluminous medical file, including diagnostic studies, the PTP reports and the AME reports, which detailed the treatment to date and the reasons for the surgical request.
The Appeals Board held the failure to review those records was a material defect, rendering the UR decision invalid and the IMR process inapplicable. The Appeals Board returned the case to the trial level to determine if the requested surgery was reasonable and necessary based on substantial medical evidence.
The Appeals Board did not provide examples of “material procedural defects.” The phrase “undermine the integrity of the UR decision” is vague enough that trial judges will likely be allowed substantial leeway in determining whether material defects exist. This case will likely lead to increased applicant filings for Expedited Hearings and attempts to bring medical treatment disputes outside of Independent Medical Review.
Defendants should ensure that UR decisions are timely and satisfy all statutory requirements. It is also clear that UR should be provided all relevant medical records, diagnostic studies and medical-legal reports. An incomplete or cursory UR decision will likely be found invalid and this case may make it substantially more difficult to limit medical disputes to the IMR process.

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