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

ARROYO vs. INLAND CONCRETE ENTERPRISES

(2016) 2016 Cal. Wrk. Comp. P.D. Lexis 10

 

Applicant sustained injury to his back, knees and right foot in July 2000. The defendant accepted the claim and provided medical treatment.

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.

After approximately 5 years of use, the scooter began to break down. The treating physician submitted a request for authorization to replace the scooter. The defendant submitted the request for authorization to Utilization Review. A Utilization Review decision issued within five working days. The reviewer, rather than deciding whether to replace or repair the scooter, non-certified the request on the grounds that a motorized scooter “non-essential to care”.

Applicant requested a hearing on the need for a replacement scooter. Defendant argued that the Workers’ Compensation judge did not have jurisdiction to decide the issue. Following a hearing, the Workers’ Compensation Judge agreed that because of the timely Utilization Review decision, he lacked jurisdiction to decide the medical necessity of the treatment requested.

Applicant filed a Petition for Removal.

The Commissioners conceded that the Utilization Review decision was timely. However, they also determined that it was invalid because it did not address the specific treatment requested by the doctor. The request was to replace the applicant’s scooter. However, the Utilization Review determination addressed the medical necessity of the scooter itself. The Commissioners held that “the Utilization Review that is conducted must address the treatment for which authorization is requested or the medical treatment in dispute”. Because the Utilization Review decision that did not address the specific treatment requested (replacement of the scooter), it was invalid and the workers compensation judge had jurisdiction to decide the issue.