Jorge Orozco was a carpenter for Southland Framers. On September 7, 2001, he sustained and industrial injury to his back, neck, and head, and filed three claims for benefits.
His primary treating physician noted in 2012 that he was ambulating with a wheeled walker and that his wife was providing continuous home care services for him. He said “Patient requires home care assistance. He is a candidate at least eight hours a day, five days a week for home care assistance to assist with bathing, dressing, food preparation, laundering, and cleaning.” The request was later increased to 12 hours a day.
On May 15, 2012, Anthem Workers’ Compensation, and the PTP agreed that, as part of the UR process, “a relatively expedited RN evaluation should be done to assess the patient’s needs.”
On July 25, 2014, 26 months after this agreement, the nurse case manager performed the evaluation. She found applicant “requires maximum assistant with the majority of his activities of daily living.” She recommended home health care assistance 12 hours per day, seven days a week to assist applicant with nutritional meal preparation, grocery shopping, grooming, hygiene, transfers into and out of the shower, bathing, dressing, transportation services and assistance in and out of vehicles, home cleaning, laundry, opening medication bottles, and verbal reminders to take medications.
The PTP reviewed nurse case manager’s report and adopted its recommendations in his own October 13, 2014 report. On October 17 he submitted an RFA to the employer.
On December 9, 2014, the RFA was denied on the grounds that the Medicare Benefits Manual indicates “services should be part-time and not exceeding 28 hours per week, and authorization should not be made if these services are regularly performed by a member of the patient’s household.” The RFA was received on November 25, 2014, and the decision to deny was made on December 8, 2014.
The WCJ found that defendant did not conduct timely utilization review of the May 9, 2012 and November 25, 2014 requests for authorization (RFAs) for home health care services. The WCJ also found that defendant was liable for home health care services after May 1, 2012, up to 12 hours a day, seven days a week.
Defendant contended on reconsideration that the WCJ erred by awarding home health care services, arguing that she should not have found that the UR determination was untimely, among other arguments. The WCAB affirmed the WCJ’s decision in the case of Orozco v Southland Framers, SCIF.
Here, the initial delay was timely. However, no UR determination issued within the statutory period, “14 days from the date of the medical treatment recommendation by the physician.” (Former L.C. § 4610(g)(l).).
The RFA was received no later than November 25, 2014. Former AD Rule 9792.9.l(e)(3), in effect at the time of defendant’s UR determination, provided in pertinent part, “[A] decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and shall be communicated to the requesting physician initially by telephone, facsimile, or electronic mail.” (Former Cal. Code Regs., tit. 8, § 9792.9.l(e)(3).
The record reflects that defendant’s UR notified the PTP of the determination on December 9, 2014, nine working days after receipt of the RFA on November 25, 2014, and four days after the statutory time period lapsed. Therefore, the Board has jurisdiction to determine the medical necessity of the requests for home health care services.