Alan Moelleken, M. D., a member of the State Fund’s MPN, recommended that applicant, Rochelle Stock, be furnished with a hospital bed for her home as treatment for her admitted 1990 injury. The request was denied after a 5/13/2014 review by Daniel Weinberg, M. D./ EK Health, the State Fund’s Utilization Review report. At a hearing brought to obtain this recommended care, Stock objected to the admission of the UR report claiming it was “inadmissible because the treatment denied was recommended by a physician in defendant’s Medical Provider Network.” The WCJ ruled the UR report was admissible and denied the request for this medical treatment in a June 20, 2014 Finding and Award.
Applicant filed a petition for reconsideration. The WCAB dismissed the petition for reconsideration, since the WCJ’s determination was not a final order subject to reconsideration. Instead it treated applicant’s petition as seeking removal to the Appeals Board. After removal the WCAB affirmed the WCJ’s Findings and Award in the panel decision of Stock v Camarillo State Hospital.
The WCAB concurred with the WCJ that applicant’s required participation in her employer’s MPN does not prohibit defendant from referring an MPN physician’s request for authorization of medical treatment to UR and Independent Medical Review. Contrary to applicant’s contentions, by its adoption of the MPN system, the Legislature did not evince an intent to preclude a defendant from seeking UR review of an MPN physician’s request for authorization of medical treatment. The law and the implementing administrative rules provide mechanisms for review of disputed treatment recommendations through UR, whether or not the treating physician is in the employer’s MPN. Both the UR provisions and the MPN provisions of the Labor Code provide that a treating physician’s request for authorization of medical treatment must be reviewed by a physician competent to evaluate the specific clinical issues, without distinction as to whether the physician is selected through the MPN. (Cf. Labor Code section 461 O(e) and Labor Code section 20 46 I 6(f).) Similarly, the definition of a primary treating physician in Administrative Director’s Rule 9767.1 and Rule 9785(a)(J) both include a physician within an MPN.
When a defendant does not approve a treatment request from applicant’s primary treating physician, the defendant must refer the request to a UR physician. Here, Dr. Moelleken’s request that applicant be provided a hospital bed was clearly intended to provide applicant relief from the effects of her industrial injury under the terms of her award of further medical treatment. She has had a two level lumbar fusion, suffers from radiculopathy, Grade 2 spondylolisthesis with instability and foraminal stenosis at two levels above the fusion. Applicant cannot sleep on a flat bed and has been sleeping in a recliner. She has been trying to obtain a hospital bed for four years. In all of that time, she has not been able to enjoy a restful night sleep.
The UR denial of the request for a hospital bed was based upon “silence” in the MTUS guidelines, and the absence of “high quality studies” and “no exceptional factors … in the documentation submitted to consider this request as an outlier to the guidelines. There is no other documentation to support the medical necessity of a hospital bed. As such, the medical necessity of the request has not been established and the request is non-certified.”
The WCAB noted that there is a hierarchy of standards to be applied to a review of the medical necessity of a request for approval of medical treatment, under Rule 9792.10.1 ( 4)(A)-(F). If the MTUS is “silent,” and there is no “peer-reviewed scientific and medical evidence,” the reviewer may consider nationally recognized professional standards, expert opinion, generally accepted standards of medical practice and “treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious.” It does not appear that the UR denial considered whether other standards may be applicable, as there was insufficient documentation or explanation provided to support the efficaciousness of Dr. Moelleken’s request. Further review of this request will be by Independent Medical Review.