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Applicant Must Treat Within the MPN when the Defendant Satisfies Access Standards
SOTO vs. SAMBRAIALO PACKAGING
(2016) 2016 Cal. Wrk. Comp. P.D. Lexis 26
Applicant sustained an admitted injury to her right shoulder, neck and low back on October 7, 2011. She was referred to the defendant’s MPN for treatment.
While the MPN included nine orthopedic doctors, only one would treat back injuries. Therefore, the applicant claimed the MPN did not meet the access standards in 8 CCR 9767.5 and selected a non-MPN physician approximately 70 miles away. The defendant refused to authorize the treatment. Applicant then agreed to select a neurosurgeon from within the MPN. However, that doctor would not accept the applicant as a patient.
Applicant requested an expedited hearing. The parties framed the issues as whether the Workers’ Compensation Judge has jurisdiction to determine whether the MPN complied with the access standards; whether the increased geographic access standard (8 CCR 9767.5(b)) for rural areas applied; whether there are at least three MPN physicians within the defined geographic area; and whether the MPN has a treating neurosurgeon.
The Workers’ Compensation Judge found that the MPN was invalid because it did not have three orthopedic specialists willing to treat the applicant; that the access standards and implementation of the MPN are within the Board’s jurisdiction; and that because the MPN is not compliant with the access standards applicant was allowed to treat outside the MPN.
Defendant filed a Petition for Reconsideration, arguing that the Workers’ Compensation Judge does not have jurisdiction to decide the validity of the MPN. Such a challenge must be through a petition filed with the Administrative Director. Further, under the rural access standards, the MPN contains more than 40 physicians qualified to act as primary treating physician and there is no requirement that a treating physician be limited to a particular specialty.
The Board granted the petition. It noted that the Division of Workers’ Compensation has designated the defendant’s place of employment as a “rural area” (8 CCR 9767.5(b)). Therefore, the defendant is required to have primary treating physicians available within 60 minutes/30 miles of applicant’s home or work and specialists within 120 minutes/60 miles. In this case, the defendant offered testimony at the hearing from its MPN medical director that the MPN contained 79 providers within 60 miles of the applicant’s ZIP Code and 33 physicians within 30 miles, any of which could treat the applicant’s condition. Therefore, there were a sufficient number of physicians available to treat the applicant. The decision noted that if the treating physician made a referral to a specialist and such a specialist was not available in the MPN, the applicant could select a non-MPN specialist.