California: WCAB Provides Guidance on Addressing Insufficient Utilization Review Documentation

The UR process requires a good faith effort by both the treating physician and the UR physician to assure that the necessary and appropriate information is available

In Smith v. Plant Construction, 2014 Cal. Wrk. Comp. P.D. LEXIS –, the WCAB panel rescinded the WCJ’s award of medical treatment to the applicant with a 6/2/2007 industrial injury to his left shoulder, lumbar spine and left knee based on his findings that the defendant’s 1/29/2014 utilization review (UR) contained material procedural defects and that substantial medical evidence supported the need for left shoulder surgery and other modalities of treatment related to surgery.

Here, the treating physician’s request for authorization (RFA) for treatment did not include information regarding the physical exam, MRI study, or prior treatment provided to the applicant necessary for the defendant to make a UR determination. The UR certification was denied after the UR physician attempted, but failed, to obtain the additional information from the treating physician.

The WCAB found that, although UR may deny treatment based on incomplete or insufficient information, the UR process requires a good faith effort by both the treating physician and the UR physician to assure that the necessary and appropriate information is available in a timely fashion to allow a proper UR determination based upon the medical evidence. The treating physician here did not include the information with his RFAs that could have addressed the documentation concern expressed in the UR denial.

Furthermore, while the UR physician attempted to obtain the information by telephoning the treating physician and waiting on hold for more than 10 minutes without making contact, the UR physician did not sufficiently endeavor to assure that such information was properly identified and obtained before issuing the UR denial.

Under these circumstances, the appropriate course of action to address the insufficient UR documentation was to allow the UR process to be properly completed in accordance with the applicable statutes and regulations through development of the record consistent with Labor Code § 4610 and 8 Cal. Code Reg. § 9792.9. 

Read the Smith noteworthy panel decision.

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