California Utilization Review: 12-Month Bar to Resubmission of RFA

WCAB finds in the absence of changed circumstances, UR determination was valid for 12 months

In Reyes v. Target, Inc., 2014 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB panel affirmed the WCJ’s finding that the applicant, who suffered an admitted industrial injury to her spine, right upper extremity and psyche, and claimed diabetes, hypertension and sleep disorder, during the period 9/4/85 through 3/30/2010, was barred under Labor Code § 4610(g)(6) from litigating a 6/17/2014 utilization review denial of her primary treating physician’s request for home care.

The WCAB found that the same treatment requested by the same physician was previously denied by UR on 3/28/2014. Furthermore, the applicant made no showing of materially changed circumstances necessitating another UR.

The WCAB concluded that, under Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp. Cases 1298 (Appeals Board en banc opinion) (Dubon II), the failure to sign the 3/28/2014 UR determination did not invalidate the determination. Therefore, in the absence of changed circumstances, the 3/28/2014 UR determination was valid for 12 months.

Moreover, the purported untimeliness of the 6/17/2014 UR determination was immaterial because under Labor Code § 4610(g)(6), the defendant could have disregarded the new request for authorization altogether and not issued any UR decision.

The WCAB pointed out that the applicant’s remedy following the 3/28/2014 UR determination was to timely request independent medical review, which the applicant did.

Read the Reyes noteworthy panel decision.

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