All medical treatment must be recommended by the physician. The physician must submit the treatment request, in writing, on a form called Request For Authorization (RFA). Once the WC carrier receives the RFA, it may either approve the RFA or send it to its Utilization Review (UR) department. The UR department has 5 business days from the day the RFA is received by the WC carrier to approve, modify, delay or deny the request. It may unilaterally grant itself another 7 calendar days to consider the RFA but may take no longer than 14 calendar days to approve, modify, or deny.
When determining whether to approve, modify or deny any treatment request, UR will use the Medical Treatment Utilization Schedule (MTUS), which is purportedly based on evidence based treatment guidelines. Think of the MTUS as a cookbook that applies to all injured workers and all injuries. Like a cookbook, it lists the criteria for a specific treatment similar to ingredients to bake a cake. If just one of the ingredients is missing, UR will not approve and you don’t get the cake (treatment), so to speak. If the MTUS doesn’t cover the specific treatment requested, then UR will use other evidence based treatment guidelines such as the American College of Occupational and Environmental Medicine or the Official Disability Guidelines.
If UR approves, you get the treatment. If it modifies, you get the treatment, but usually not as much as requested. One example would be if the doctor recommends 6 weeks of PT, 3x/wk, and UR says let’s try 2 weeks and come back after that if you think you need more. If UR denies the request, the doctor may appeal the UR denial and the same deadlines apply. A UR denial is valid for one year if the same physician makes the same treatment request unless that physician has documented a change in your condition that was material to the initial UR’s decision to deny. In practical terms, this means you must wait one year before the WC carrier will consider the requested treatment again unless a different physician is making the treatment request.
Any UR denial may be sent for Independent Medical Review (IMR). IMR is a program run by the Department of Industrial Relations to handle appeals of UR denials. It has contracted with a company called Maximus to handle all IMRs of UR denials in the State of California for all injured workers. If you would like to learn more about this company, please use this link: http://www.maximus.com.
Maximus uses physicians to evaluate the RFA and UR Denial. These physicians are anonymous. We have no idea of the qualifications of the physicians used to perform the IMR or of their experience, training, knowledge, or education. There is no guarantee that the reviewing physician will have any expertise in the specialty of your treating physician. Like UR, IMR will use the MTUS to determine if the treatment is reasonably medically necessary. The law requires IMR to reach a decision within 30 days after it receives all information material to the UR denial. Unfortunately, there is no remedy if IMR takes longer and we have seen IMR decisions that have taken more than 6 months to issue. However, any IMR decision is final and there is no right of appeal. If IMR upholds the UR denial, the WC carrier will not pay for the treatment.
If you would like to learn more about the IMR process, you can use this link at the DIR website: http://www.dir.ca.gov/dwc/IMR.htm.
In addition, we will evaluate the UR denial to determine if there are technical reasons why it should be considered invalid. If we are able to identify such a reason, we will file a request with the Worker’s Compensation Appeals Board (WCAB) to decide whether you should get the treatment despite the UR denial. The WCAB will set a hearing, often within 30 days, to conduct a trial on the question of the validity of the UR denial and issue a decision 30 days thereafter.