By Hon. Susan V. Hamilton, Former Assistant Secretary and Deputy Commissioner, California Employees’ Compensation Appeals Board
Utilization Assessment (UR) to find out the appropriateness and necessity of requested medical therapy in a well timed method primarily based on accepted medical requirements and pointers has been a compulsory element of California’s staff’ compensation system for over twenty years. In that point, we now have turn out to be used to the method and the distinct roles of the treating doctor, the UR reviewer, the employees’ compensation choose (WCJ), unbiased medical evaluation (IMR) and the Employees’ Compensation Appeals Board (WCAB). One facet of the UR course of, nonetheless, continues to confound treating physicians and practitioners alike: the weather of a correct request for an expedited evaluation of a therapy request. A current WCAB panel determination clarifies the requisite parts of a request for authorization (RFA) of therapy by an expedited evaluation. The case is Castellanos v. Greatest Purchase, Inc. (Might 10, 2024, ADJ18538112) 2024 Cal. Wrk. Comp. P.D. LEXIS 122.
The Details
Treasured Castellanos (applicant), whereas employed by defendant on November 26, 2023, claims to have sustained harm arising out of and occurring in the midst of her employment to her head, neck, mind, and proper arm. Applicant was seen within the emergency room on November 26, 2023, and was discharged the identical day with the advice that she comply with up together with her main care doctor. Applicant was subsequent seen by Dr. Yury Furman, who reported on November 30, 2023, with the advice that applicant be handled with acupuncture, strengthening, endurance and cardio train, and drugs for ache. Dr. Furman positioned applicant on short-term complete incapacity.
Dr. David Patterson then grew to become applicant’s treating doctor. On January 5, 2024, Dr. Patterson submitted a request for authorization (RFA) during which he requested sure completely different therapy modalities, together with 12 visits to an outpatient transitional residing heart day therapy program the place applicant would obtain as much as six hours of bodily, occupational, speech remedy and neuropsychology, together with transportation to and from this system. On the RFA Dr. Patterson chosen the field for an expedited evaluation.
5 days later, on January 10, 2024, defendant issued its UR determination, denying authorization of the outpatient transitional residing heart day therapy program.
Applicant then requested an expedited listening to, contending that defendant’s UR denial was premature as a result of it was not accomplished inside the 72-hour interval supplied for an expedited evaluation and, due to this fact, the WCAB had jurisdiction to find out her entitlement to the outpatient transitional residing heart day therapy program as cheap and mandatory medical therapy.
An expedited listening to was held on February 14, 2024, and some days after the listening to, the WCJ issued a Findings and Order (F&O) during which it was discovered that the January 10, 2024, UR determination was well timed and the WCAB lacked jurisdiction to find out the dispute. Within the opinion that accompanied the F&O, the WCJ defined that though Dr. Patterson requested an expedited evaluation by checking the expedited evaluation field on the highest of the RFA type, he didn’t substantiate that applicant confronted an imminent or severe menace to her well being and security such {that a} UR determination issued inside the regular five-day timeframe could be detrimental to her well being.
Applicant sought reconsideration of the F&O, arguing that the WCJ improperly shifted the burden of proof on her to display the reasonableness and necessity of the therapy requested by her treating doctor.
The Panel’s Evaluation
The panel begins its evaluation with the commentary that applicant’s petition for reconsideration cites as authority a panel determination in Rodriguez v. Air Eagle, Inc., 2015 Cal. Wrk. Comp. P.D. LEXIS 3 (Appeals Board noteworthy panel determination), and features a assertion represented to be a direct quote from the Rodriguez determination, as follows: “[t[he objective of the verify field is to alert the reviewer {that a} separate timeframe for the choice applies, and there may be nothing in Rule 9792.9.1. …which permits a defendant to override a requesting doctor’s designation of a request as imminent and severe. Thus, the… RFA ought to have been handled as an expedited request.”
The panel factors out that the quoted textual content from Rodriguez, supra, nonetheless, is incomplete and the complete citation really reads: “[t[he objective of the verify field is to alert the reviewer {that a} separate timeframe for the choice applies, and there may be nothing in Rule 9792.9.1 because it existed in 2013 which permits a defendant to override a requesting doctor’s designation of a request as imminent and severe.”
This omission of the phrase, “because it existed in 2013,” isn’t just a matter of semantics—it’s important as a result of Rule 9792.9.1 was amended and the amended model is relevant to dates of harm on or after January 1, 2013, which incorporates applicant’s case. The amended model of the rule now states:
Potential or concurrent choices to approve, modify, delay, or deny a request for authorization associated to an expedited evaluation shall be made in a well timed style acceptable to the injured employee’s situation, to not exceed 72 hours after the receipt of the written data moderately essential to make the willpower. The requesting doctor should certify in writing and doc the necessity for an expedited evaluation upon submission of the request. A request for expedited evaluation that’s not moderately supported by proof establishing that the injured employee faces an imminent and severe menace to his or her well being, or that the timeframe for utilization evaluation below subdivision (c)(3) could be detrimental to the injured employee’s situation, shall be reviewed by the claims administrator below the timeframe set forth in subdivision (c)(3).
The panel then summarizes the necessities for requesting an expedited evaluation below the relevant model of Rule 9792.9.1. First, the requesting doctor should certify and doc in writing the explanation(s) why an expedited evaluation is critical. Second, the documentation should set up that the injured employee faces an imminent and severe menace to their well being or, third, that the conventional five-day timeframe for UR could be detrimental to the injured employee’s well being. In absence of such written certification and documentation, Rule 9792.9.1 states that the RFA shall be reviewed below the five-day timeframe set forth in subdivision (c)(3) of the rule.
In its software of the underlying information to Dr. Patterson’s RFA, the panel quotes from the WCJ’s Report and Advice on Petition for Reconsideration (R&R). The R&R states that even on a liberal studying of the RFA, Dr. Patterson didn’t present any documentation that applicant faces an imminent or severe menace to her well being and security such {that a} evaluation below the common five-day timeframe could be detrimental to her well being. On the contrary, Dr. Patterson merely states his perception that applicant would profit from the outpatient program. The WCJ then references Diaz v. Pacific Coast Framers, Inc., 2023 Cal. Wrk. Comp. P.D. LEXIS 211 (Appeals Board noteworthy panel determination), during which a panel held that the doctor’s RFA was correctly reviewed below the five-day interval in subdivision (c)(1) of Rule 97929.1 the place the RFA and physician’s reviews failed to ascertain that applicant’s situation posed a severe and imminent menace to his well being that will warrant an expedited evaluation. The WCJ states he discovered Diaz, supra, persuasive and relevant.
The panel states its settlement with the WCJ’s evaluation of Rule 9792.9.1(c)(4) {that a} RFA requesting expedited evaluation should moderately set up that the injured employee faces an imminent and severe menace to their well being, or that the timeframe for a routine, non-expeditious evaluation could be detrimental to the injured employee’s well being. Absent such written certification and documentation, the RFA might be reviewed inside the timeframe contained in subdivision (c)(3), which is 5 enterprise days from receipt of the RFA or to not exceed 14 days.
The panel then concludes that Dr. Patterson’s January 5, 2024, RFA failed to satisfy the criterion for expedited evaluation below Rule 9792.9.1(c)(4) as a result of it didn’t clarify why or how applicant confronted an imminent and severe menace to her well being or how a routine UR evaluation of the RFA could be detrimental to her well being. Dr. Patterson merely acknowledged his perception that applicant would profit from the really helpful therapy. Having failed to satisfy the criterion for an expedited evaluation, the January 5, 2024, RFA was correctly reviewed below the usual for non-expeditious evaluation set forth in Rule 9792.9.1(c)(3). Right here, defendant carried out the evaluation inside 5 enterprise days, making it well timed, and, accordingly, the WCAB has no jurisdiction over the problem.
Takeaways
The principle level of Castellanos is crystal clear: Rule 9792.9.1(c)(4) specifies the required parts of a correct request for an expedited evaluation of a medical therapy request, and the requesting doctor should present adequate data inside the physique of the request to ascertain an imminent and severe well being to the injured employee’s well being and security or in any other case clarify how a non-expeditious evaluation could be detrimental to the injured employee’s well being. Except that documentation is included within the request, the RFA might be reviewed below the timeframe for non-expeditious requests.
There’s a secondary level that’s equally essential. When quoting a reference, be it from case, statute, or rule, and so on., make sure that the quote is correct and doesn’t omit any pertinent language.
Reminder: Board panel choices usually are not binding precedent.
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