Frank Diaz claimed injury to his head, neck, back, shoulders, chest, ribs, hips, and buttocks, while employed by Pacific Coast Framers as a construction worker on April 16, 2020.

On August 22, 2023, treating physician Dr. Miller issued an RFA wherein he requested a re-evaluation with neurologist, Dr. Nudleman, a re-evaluation with Dr. Salkinder, an ENG/VNG [electronystagmogrophy/videonystagmography] examination, six sessions of vestibular rehabilitation, a nurse evaluation for home care needs, and a request for 30-day inpatient at Casa Colina with physiatrist Dr. Patterson and neuropsychological evaluation with Dr. Elizabeth Cisneros.

Regarding the 30-day Casa Colina inpatient request, Dr. Miller stated, “This is an expedited request.”

The August 31, 2022, UR recommendation, stated that the request was first received by State Compensation Insurance Fund on August 26, 2022, and was received by Genex (UR) on August 30, 3022.

The UR recommendation certified/authorized the requested treatment except for the 30-day Casa Colina inpatient request that was non-certified. It also stated that Dr. Miller’s request for expedited review was not “accompanied by evidence reasonably establishing that the injured worker faces an imminent and serious threat to his … health; or that the timeframe for utilization review under 8CCR 9792.9.1(c)(3) would be detrimental to the injured workers’ condition.”

The parties went to trial raising as one of the issues whether the UR denial, dated August 31st, 2022, in regard to PTP Dr. Lawrence Miller’s RFA, dated August 22nd, 2022, was untimely inasmuch as applicant contends the RFA called for expedited review.

The WCJ found that the August 31, 2022 Utilization Review [UR] was timely so the Appeals Board does not have jurisdiction to determine whether the medical treatment and services requested by Lawrence Miller, M.D., pertaining to the Casa Colina referral, is reasonably required to cure or relieve applicant from the effects of his industrial injury. Applicant’s Petition for Reconsideration was denied in the panel decision of Diaz v Pacific Coast Framers -ADJ14244911 (August 2023).

The Labor Code section 4610-time limits within which a UR decision must be made are mandatory. The Appeals Board has jurisdiction to determine whether a UR decision is timely.

However, the Appeals Board does not have jurisdiction to address whether treatment requested in a timely UR decision is reasonably required. The “IMR process is the exclusive mechanism for review of a utilization review decision.” (King v. CompPartners, Inc. (2018) 5 Cal.5th 1039, 1048 [83 Cal.Comp.Cases 1523]; Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc).)

Here, as explained by the WCJ: “Dr. Miller was required to document at the time of submission of the RFA, that the applicant is facing an imminent or serious threat to his health or safety or that the normal UR timelines would be detrimental to the applicant’s life or health and the reasons, therefore. Dr. Miller did not do so.”

“In total, between the two trials conducted in this case, applicant offered, and this Court admitted 22 separate exhibits. Of those exhibits, Applicant’s Exhibits 1 through 17 pre-date Dr. Miller’s report and RFA dated August 22, 2022. Despite Petitioner’s representation to the contrary, not one of those medical reports document that applicant is facing an imminent or serious threat to his health or safety or that applicant presented a danger to himself and to those around him. Further, none document that applicant required in-patient care at Casa Colina.“

Having reviewed the trial record, the WCAB Panel agreed with the WCJ that none of the reports from Dr. Miller constitute evidence that applicant’s condition was an imminent and serious threat to his health that would warrant the 72-hour expedited review delineated in AD rule 9792.9.1(c)(4).