No denial of care within the MPN was shown; treatment was ongoing and authorized by defendant.
Favours Defendant prevailed
This fact supports the denial of the petition for reconsideration and the finding that applicant was not free to select an out-of-network PTP.
From the decision · page 4The designation of RMS as PTP was insufficient to wrest defendant's
control of treatment within the MPN. The status of Chrislip Hervatin as
applicant's attorney was in question without the statutorily required filing to take
over applicant's representation. More importantly, no denial of care has been
shown though it is alleged based on Lien Claimant's Exhibit 5, letter of
05/31/2016. This letter appears to only be addressed to applicant, and references
a request for authorization dated 05/30/2016 without identifying the requesting
party. There is no 05/30/2016 RFA in evidence. The letter refers to 8 Cal. Code
of Reg. Sec. 9792.9.1 (b) (1) which relates to the UR deferral process. The letter
contains an incomplete sentence stating "This treatment is disputed because"
with no words following. Whatever the author of this letter might have intended,
it does not demonstrate that defendant was denying care within the MPN. Rather,
it appears to be the use of an incorrect template and possibly misdirected. The
claim itself was never denied, and the treatment within the MPN was last
documented by Defendant's Exhibit V, report of Dr. Aflatoon, 01/05/2016, who
recommended further treatment.
PQME Dr. Kim found AMA impairments requiring permanent disability indemnity, which was resolved by compromise and release.
Favours Defendant prevailed
Supports the finding that defendant met its obligation to provide benefits and no additional liability for out-of-network treatment was required.
From the decision · page 5In this case PQME Dr. Kim found that applicant had AMA impairments,
which required defendant to provide permanent disability indemnity, liability
for which was resolved by compromise and release approved on 09/25/2017