California: UR Defective for Lack of Documentation When Neither Party Challenged WCJ’s Finding

In Jovel v. Sisters of the Holy Names, 2014 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB panel affirmed the WCJ’s finding that the defendant’s utilization review non-certification of the treating physician’s request for authorization to perform arthroscopic knee surgery to treat the applicant’s right knee injury “was defective” because certain documentation was not provided to the UR reviewer. The WCAB further held that the requested knee surgery and related items were supported by substantial medical evidence and, consequently, there was no basis for returning the matter to UR as the WCJ had ordered.

The WCAB determined that, although the WCJ found the defendant’s UR defective for lack of documentation as described in Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp. Cases 313 (Appeals Board en banc opinion) (Dubon I) and not because UR was untimely based upon the subsequent holding in Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp. Cases 1298 (Appeals Board en banc opinion) (Dubon II) (under which UR is only invalid if it is untimely), neither the applicant nor the defendant challenged the WCJ’s finding that UR was defective and thereby waived any objection to this finding pursuant to Labor Code §§ 5902 and 5904 and 8 Cal. Code Reg. § 10842.

Since the UR was determined to be defective, the WCAB had authority under Dubon I and Dubon II to determine the medical necessity of the requested arthroscopic surgery based on substantial evidence.

According to the WCAB, the evidence reflected that the course of conservative treatment for the applicant’s knee injury, including physical therapy and injections, did not successfully relieve her symptoms. The WCAB further found that the MRI findings supportive of surgical treatment constituted substantial evidence that the surgery was reasonably required to cure or relieve the applicant from the effects of her right knee injury as set forth in Labor Code § 4600.

Read the Jovel noteworthy panel decision.

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