Lisa Weilmann and the employer United Temporary Services resolved this case by way of Stipulated Award on 7/18/02. The award provided future medical treatment to bilateral upper extremities, neck, fibromyalgia and psyche. The current dispute between the parties involved four UR denials. Two involved a request for Botox to treat migrain, an two were a request for Xyrem for shoulder tendentious, The employer’s UR physicians declined to authorize the treatment. The applicant proceeded to hearing and the WCJ found defendant’s UR denials invalid and ordered the employer to provide treatment without finding a medical necessity.
The applicant claimed that there were three material defects in the UR process. One error was the lack of a signature on the UR decision. Pursuant to the Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 313 decision the WCJ ruled that “the absence of a signature on the UR decision is not a minor defect.” Although the WCJ noted that the absence of a signature does not make the report inadmissible pursuant to regulation 10606, but will be considered in weighing the evidence. Nonetheless, no particular rationale was given in the Opinion on Decision as to why a signature was that important.
A second claimed UR defect involved the failure of the employer to provide UR with necessary medical records including prior reports of an AME. In this regard the WCJ held that “because of the complexity of the case the UR reviewers should have either asked for the prior medical reports of the AME or the prior reports should have been given to them.
A third claimed UR defect involved the lack of the UR physicians having appropriate board specializations in the medical areas under review. Labor code 4610 ( e) has a two-tier test. First it must be found that the doctors are competent to evaluate the specific clinical issues. Second, the services must be within the scope of the physicians practice. The WCJ was unable to find that the UR physicians met this test.
The WCJ ordered the defendants to provide the requested medical care without finding medical necessity based upon substantial medical evidence. The employer appealed and the WCAB granted reconsideration in the case of Lisa Weilmann v United Temporary Services.
The WCAB concurred with the WCJ’s determination that the the failure of all of the reviewing physicians to sign their reports and the failure to provide the relevant AME reports that explain necessity for the requested treatments, are sufficient to undermine the integrity of the UR decisions and renders invalid the UR determinations in this case. It did not however agree with her determinations with respect to a lack of the correct medical specialization.
But the WCAB went to to rule that “a finding that the UR determination is not valid to deny the requested treatment does not mandate hat the treatment be authorized. As held in Dubon, the applicant must still provide substantial medical evidence to establish that the requested treatment is reasonable and necessary. After finding the UR determinations were invalid in this case, the WCJ ordered defendant to provide the request treatments without making findings that the treatments are reasonable and necessary. Accordingly, we shall grant reconsideration to amend the Findings of Fact and Order to defer the order authorizing the disputed Xyrem and Botox treatments, pending a determination as to whether the treatments are reasonable and necessary.”