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Dubon v. World Restoration II (10/6/2014)

WCAB 2014 En Banc Decision

Jose Dubon v. World Restoration, Inc.; and State Compensation Insurance Fund (Oct. 6, 2014)

  • Case No: ADJ4274323 (ANA 0387677) - ADJ1601669 (ANA 0388466)
  • 79 Cal. Comp. Cases 1298
  • 2014-EB-7

Summary

After granting reconsideration of its prior en banc decision in order to further review and study the issues, the Appeals Board issued its decision after reconsideration wherein it rescinded its en banc decision of February 27, 2014, affirmed the workers’ compensation administrative law judge’s decision, which determined that the medical necessity of applicant’s requested back surgery must be determined by independent medical review (IMR), notwithstanding any procedural defects in defendant’s timely utilization review (UR) decision, and held as follows:

  1. A UR decision is invalid and not subject to independent medical review (IMR) only if it is untimely;
  2. Legal issues regarding the timeliness of a UR decision must be resolved by the Workers’ Compensation Appeals Board (WCAB), not IMR;
  3. All other disputes regarding a UR decision must be resolved by IMR;
  4. If a UR decision is untimely, the determination of medical necessity may be made by the WCAB based on substantial medical evidence consistent with Labor Code section 4604.5.

Note: Frequently referred to as Dubon II.

Additional Information

California Labor Code § 4604.5

Department of Industrial Relations En Banc Decisions

DaisyBill Resources

Blog: Your Request for Authorization (RFA) Questions Answered
Blog:
WCAB Emphasizes UR Decisions

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