Incomplete Utilization Review Report is Untimely

Summary Written by Larry Fields

Most of us are aware that an untimely utilization review (UR) report is deemed defective such that the WCAB has jurisdiction to decide whether the requested treatment is necessary, thereby precluding Independent Medical Review (IMR).  But what about a timely UR report that is served on parties where there are missing pages or is otherwise incomplete in that regard?   Does the WCAB have jurisdiction to hear the issue or is it solely within the realm of IMR?

This situation came up recently in the case of Ingle v. Department of Motor Vehicles which was a Board Panel Decision at 2017 Cal. Wrk. Comp. P.D. Lexis 137.  In that case applicant sustained an accepted dental injury as was treating with a periodontist, Dr. Benarroch, who issued a Request for Authorization (RFA) of numerous dental procedures necessary to treat her injury.  Also, the parties stipulated that the RFA was timely submitted to UR and that the defendant’s UR reviewer issued a time decision which included some modifications and denials of the RFA.

That wasn’t the problem.  The problem was that the UR decision which consisted of 25 pages, while being timely served on applicant’s attorney was incomplete.  In other words, the attorney only received the first 20 pages of the 25 page decision.  In particular, what was missing in those last 5 pages was important information such as the name/qualifications of the UR reviewer, the list of medical records reviewed, and notification of the UR appeals process.  The attorney therefore argued that he did not have all of the information to which he was legally entitled pursuant to 8 Cal. Code Reg. §9792.9.1(e)(5).  He argued that this was an untimely denial.  As such, he argued failure to timely communicate all of the required information renders the UR decision untimely per Bodam v. San Bernardino County Department of Social Services (2014) 79 Cal. Comp. Cases 1519; and per Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp. Cases 1298, the Appeals Board has jurisdiction to decide the treatment request where the UR decision is untimely.

The defendant argued that this was merely a “procedural defect” not rendering the UR decision untimely and that IMR was the proper remedy.  The Board panel rejected this argument because the fact that important information contained in the last 5 pages of the UR decision was missing there was a violation of §9792.9.1(e)(5) rendering the UR decision being untimely.

So, for those of you that do rely on the UR decision making process should make sure that when the decision is served on the applicant, the doctor, and applicant’s attorney that the complete decision is served.

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