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Shanley v. Henry Mayo Newhall Memorial Hospital (2014)

WCAB Panel Decision

Victoria Shanley v . Henry Mayo Newhall Memorial Hospital; and Travelers Insurance Co. (2014)


Summary

In rescinding the Workers’ Compensation Judge’s finding that defendant’s two Utilization Review (UR) decisions were timely communicated to the requesting physician, the Appeals Board relied on Dubon II and Bodam to hold that defendant's UR decisions which denied requests for a lumbar MRI and for an EMG of the lower extremities were invalid because defendant failed to prove timely communication of the two UR decisions to the requesting physician by phone, fax, or email within 24 hours after the decisions had been made.

The UR decision states phone messages were “left” for the treating provider, without indicating the content of the phone messages and did not prove that those messages gave the treating physician sufficient notice that the defendant denied the treatment requests. Further,  statements that “[p]eer to peer [contact] was unsuccessful” failed to prove that the UR decision was communicated to the treating physician by phone within 24 hours after making the UR decision.

Moreover the Appeals Board held that if a UR decision is untimely, the determination of medical necessity must be made by the WCAB instead of by Independent Medical Review.

Additional Information

California Labor Code § 4610

California Labor Code § 4610.6

California Code of Regulations § 9792.9.1(e)(3)

DaisyBill Resources

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

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