What the panel ordered
Reconsideration granted; prior Findings and Order dated July 29, 2025 rescinded; new Findings substituted; matter returned to WCJ for further proceedings on medical necessity of requested treatment.
Applicant sought reconsideration of the Findings and Order issued on July 29, 2025, which denied expedited review and found the Utilization Review determination timely; the WCAB granted reconsideration, rescinded the prior Findings and Order, and returned the matter to the WCJ for further proceedings.
What was disputed, and how it came out
Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.
The WCAB found that the defendant's March 26, 2025 UR determination was untimely because no medical professional reviewed the expedited request within the required 72-hour timeframe, thus vesting jurisdiction in the WCAB to determine medical necessity.
From the decision · page 8submitted on March 21, 2025 established the need for expedited review, or that any such determination was communicated to the prescribing physician within 72 hours of defendant's receipt of the RFA. As a result, defendant's March 26, 2025 UR decision was untimely, and the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].) Accordingly, we will grant reconsideration, rescind the F&O, substitute new Findings of Fact that defendant's March 26, 2025 UR determination was untimely, and return this matter to the WCJ for determination of whether applicant has met the burden of establishing that the requested medical treatment is medically necessary under applicable medical treatment utilization schedule and recommended guidelines. (Lab. Code, § 4604.5; 5307.27 et seq.)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant's March 26, 2025 UR determination was not reviewed by a medical professional within the required 72-hour timeframe for expedited review.
Favours Applicant prevailed
This failure rendered the UR determination untimely, vesting jurisdiction in the WCAB to decide the medical necessity of the requested treatment.
From the decision · page 8submitted on March 21, 2025 established the need for expedited review, or that any such determination was communicated to the prescribing physician within 72 hours of defendant's receipt of the RFA. As a result, defendant's March 26, 2025 UR decision was untimely, and the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].) Accordingly, we will grant reconsideration, rescind the F&O, substitute new Findings of Fact that defendant's March 26, 2025 UR determination was untimely, and return this matter to the WCJ for determination of whether applicant has met the burden of establishing that the requested medical treatment is medically necessary under applicable medical treatment utilization schedule and recommended guidelines. (Lab. Code, § 4604.5; 5307.27 et seq.)
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Submitted two RFAs dated March 20, 2025, requesting expedited review for treatment; opinion supported need for expedited review under Labor Code section 4610(i)(3).
Dr. Prasad's opinion provided the basis for expedited review which was not timely acted upon by defendant, supporting the finding of untimeliness.
From the decision · page 1Applicant seeks reconsideration of the Findings and Order (F&O) issued on July 29, 2025, in which the workers' compensation administrative law judge (WCJ) found, in pertinent part, that the request for authorization (RFA) submitted by Vibhay Prasad, M.D., on March 20, 2025 failed to meet their burden of proof to demonstrate a need for expedited review, and that the Utilization Review determination (UR) performed by Genex was timely and valid.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code
Labor Code section 4610(i)(3)
Requires expedited review within 72 hours for requests where the employee faces an imminent and serious threat to health.
From the decision · page 5If the employee's condition is one in which the employee faces an imminent and serious threat to the employee's health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision making process, as described in paragraph (1), would be detrimental to the employee's life or health or could jeopardize the employee's ability to regain maximum function, decisions to approve, modify, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees shall be made in a timely fashion that is appropriate for the nature of the employee's condition, but not to exceed 72 hours after the receipt of the information reasonably necessary to make the determination.
California Code of Regulations, title 8, section 9792.9.1(c)(4)
WCAB Rule 9792.9.1(c)(4)
Mandates that expedited review decisions be made within 72 hours by a medical professional certifying the need for expedited review.
From the decision · page 6(4) Prospective or concurrent decisions to approve, modify, delay, or deny a request for authorization related to an expedited review shall be made in a timely fashion appropriate to the injured worker's condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. The requesting physician must certify in writing and document the need for an expedited review upon submission of the request. A request for expedited review that is not reasonably supported by evidence establishing that the injured worker faces an imminent and serious threat to his or her health, or that the timeframe for utilization review under subdivision (c)(3) would be detrimental to the injured worker's condition, shall be reviewed by the claims administrator under the timeframe set forth in subdivision (c)(3).
Labor Code
Labor Code section 5909
Requires the Appeals Board to act on petitions for reconsideration within 60 days of case transmission.
From the decision · page 4Former section 5909 provided that a petition for reconsideration was deemed denied unless the Appeals Board acted on the petition within 60 days from the date of filing. (Lab. Code, § 5909.) Effective July 2, 2024, section 5909 was amended to state in relevant part that:
What proof carried it
The evidence the panel weighed, by kind.
No evidence that a medical professional reviewed the expedited request within 72 hours as required by AD Rule 9792.9.1(c)(4).
From the decision · page 8submitted on March 21, 2025 established the need for expedited review, or that any such determination was communicated to the prescribing physician within 72 hours of defendant's receipt of the RFA. As a result, defendant's March 26, 2025 UR decision was untimely, and the WCAB is vested with jurisdiction over the underlying medical treatment dispute. (Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 [2014 Cal. Wrk. Comp. LEXIS 131].) Accordingly, we will grant reconsideration, rescind the F&O, substitute new Findings of Fact that defendant's March 26, 2025 UR determination was untimely, and return this matter to the WCJ for determination of whether applicant has met the burden of establishing that the requested medical treatment is medically necessary under applicable medical treatment utilization schedule and recommended guidelines. (Lab. Code, § 4604.5; 5307.27 et seq.)
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About this page
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