Martha Reyes sustained and admitted industrial injury while working for Target. Her primary treating physician Dr. Sobol submitted a Request for Authorization on 02/25/2014 seeking authority for “home care assistance 4 hrs/day x 3 days/wk x 6 wks for cooking/cleaning/laundry/med [illegible].” Utilization Review evaluated the request and denied it on 03/28/2014. The applicant did not claim any material defect in the UR decision. Applicant claims to have sought IMR of the UR decision which had not been decided as of the following events.
The Sobol Orthopedic Medical Group then submitted a second similar request on 05/22/2014. He again requested “Home Care Assistance, 4 hours/ day, 3 days/week for 6 weeks,” The form indicates it to be a “New Request” rather than a “Resubmission – Change in Material Facts.” The request was untimely denied by Utilization Review on 06/17 /2014. This untimely 06/17 /2014 UR denial forms the basis of the present controversy.
Applicant filed a 07/10/2014 Declaration of Readiness to proceed to Expedited Hearing, voicing an objection to the 06/17 /2014 Utilization Review Determination as being untimely, and not based on substantial medical evidence. Defendant filed a timely objection to the DOR.
The matter proceeded to Expedited Hearing on 08/21/2014. Submitted for decision was the applicant’s need for further medical treatment generally (in the context of the 06/17 /2014 utilization review decision.) The WCJ determined that Labor Code § 4610(g)(6) bars applicant from litigating the 06/17 /2014 Utilization Review denial, as the same requested treatment was previously denied by Utilization Review on 03/28/2014, and there had been no showing of material change in circumstance necessitating another utilization review. Applicant filed the instant Petition for Reconsideration on 09/16/2014 which was denied in the panel decision of Reyes v Target Inc.
The WCAB panel concluded “Because the March 28, 2014 UR decision was not invalid, then in the absence of changed circumstances (not alleged here), that UR decision “shall remain effective for 12 months from the date of the decision without further action by the employer with regard to any further recommendation by the same physician for the same treatment.” (Lab. Code, § 4610(g)(6).) Accordingly, it is immaterial that applicant’s physician’s May 22, 2014 request for authorization (RFA) was not denied by defendant until June 17, 2014, even though that denial otherwise might have been deemed untimely had it been an initial RFA. (Lab. Code,§ 4610(g)(3).) Under section 4610(g)(6), defendant could properly have disregarded the new RFA and not issued a UR decision at all.”