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Seminar Archives

Remember To Let the Good Times Roll – We Do Win Them Once in a While

An untimely UR decision does not require automatic authorization of the requested treatment.

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Happy New Year- Don’t Forget to Object and File your Petition and DOR!

If defendants remain diligent upon receipt of disputed med-legal bills and follow the timelines and procedures of CCR §10786 and the corresponding Labor Code sections, success is not guaranteed but much more likely.

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Exempt Drugs and Utilization Review

The latest argument being advanced by the applicant community is that “exempt” medications are not subjected to Utilization Review. We disagree.

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Defendants Utilization Review Obligation is Not Triggered Absent a Request for Authorization

Applicant sustained various injuries while working as an anesthesia technician. The injuries resulted in 100% permanent disability. In November 2013, the applicant had a walk-in bathtub installed because of stability issues which resulted in several falls. In addition, the tub had hydrotherapy jets which the applicant believed helped with her pain relief.

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Utilization Review Must Address the Treatment Specified in the Request for Authorization

In 2008, the Agreed Medical Evaluator was deposed and testified that it was medically reasonable for the applicant to use a motorized scooter. He reiterated that opinion in a report dated March 12, 2009. Based on those opinions, the defendant provided the applicant with a motorized scooter.

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Defendant Must Conduct Timely Retrospective Utilization Review Once Liability for Injury is Established

Applicant was an employee of United Parcel Service who claimed multiple injuries including intracranial hemorrhage, hypertension, sleep disorder, vision and psyche through August 2006. Defendant denied the claims. After several years of litigation, the case was tried and the injuries were found to be compensable on April 12, 2013. The defendant filed a Petition for Reconsideration which was denied on June 21, 2013.

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Applicant Entitled to Additional Period of Temporary Disability Following Self-Procured Medical Treatment

The applicant underwent shoulder surgery on August 11, 2011. However, the surgery did not alleviate her symptoms. Her treating physician referred her for a consultation with another surgeon who diagnosed the applicant with right shoulder rhomboid detachment. He recommended surgery to correct the detachment on December 15, 2014.

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Utilization Review Physicians May Owe Duty of Care to Applicants

Applicant sustained an injury to his back on February 15, 2008. In 2011 he developed anxiety and depression, allegedly as a compensable consequence of his back pain and his treating physician prescribed Klonopin. The defendant provided the Klonopin until 2013 when they first submitted the prescription for Utilization Review.

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