What the panel ordered
Defendant's Petition for Reconsideration of the May 8, 2025 Findings of Fact and Orders is granted; final decision after reconsideration is deferred pending further review of the merits and the entire record.
Defendant sought removal of the WCJ's Findings of Fact and Orders issued May 8, 2025, challenging the order to provide medical treatment; the WCJ issued a Report and Recommendation to deny reconsideration; the WCAB granted defendant's Petition for Reconsideration and deferred final decision pending further review.
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 WCJ found the UR denial dated April 15, 2025 was untimely because the defendant had the requested information from prior RFAs, thus WCAB has jurisdiction to determine medical necessity. Defendant challenged this finding, arguing the RFA was new and the denial was timely. The WCAB granted reconsideration to further study the issue of change in circumstances.
From the decision · page 1Defendant seeks removal in response to the Findings of Fact and Orders (F&O) issued on May 8, 2025, wherein the workers' compensation administrative law judge (WCJ) found in pertinent part that while employed during the period July 21, 1995 through March 23, 2020, as a Correctional Officer by defendant Corcoran State Prison, applicant sustained injury arising out of and in the course of employment to the neck, the back, and the ears (hearing loss). The WCJ further found that the Request for Authorization (UR) was received by carrier on April 1, 2025; that defendant and EK Health were served with the medical information requested on two occasions prior to the denial letter of April 15, 2025; and that the denial dated April 15, 2025 was untimely (Cal. Code Regs., tit. 8, § 9792.1.9 (e) (5) (F)). He ordered defendant to provide medical treatment in accordance with the RFA issued by Dr. Rasouli dated April 15, 2025.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The WCJ found the UR denial dated April 15, 2025 was untimely because EK Health had the requested information from prior RFAs submitted by Dr. Rasouli on July 12, 2024 and October 15, 2024.
Favours Applicant prevailed
This finding supported WCAB jurisdiction to determine medical necessity and to order medical treatment, favoring the applicant.
From the decision · page 1Defendant seeks removal in response to the Findings of Fact and Orders (F&O) issued on May 8, 2025, wherein the workers' compensation administrative law judge (WCJ) found in pertinent part that while employed during the period July 21, 1995 through March 23, 2020, as a Correctional Officer by defendant Corcoran State Prison, applicant sustained injury arising out of and in the course of employment to the neck, the back, and the ears (hearing loss). The WCJ further found that the Request for Authorization (UR) was received by carrier on April 1, 2025; that defendant and EK Health were served with the medical information requested on two occasions prior to the denial letter of April 15, 2025; and that the denial dated April 15, 2025 was untimely (Cal. Code Regs., tit. 8, § 9792.1.9 (e) (5) (F)). He ordered defendant to provide medical treatment in accordance with the RFA issued by Dr. Rasouli dated April 15, 2025.
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.
Dr. Rasouli authored multiple RFAs for back surgery, including the April 1, 2025 RFA for L4-5, L5-S1 Anterior Lumbar Interbody Fusion. The WCJ found the April 15, 2025 UR denial untimely as EK Health had the requested information from prior submissions by Dr. Rasouli, supporting medical necessity for treatment.
The WCJ relied on Dr. Rasouli's RFAs and the timing of information submissions to find the UR denial untimely and to assert WCAB jurisdiction.
From the decision · page 1Defendant seeks removal in response to the Findings of Fact and Orders (F&O) issued on May 8, 2025, wherein the workers' compensation administrative law judge (WCJ) found in pertinent part that while employed during the period July 21, 1995 through March 23, 2020, as a Correctional Officer by defendant Corcoran State Prison, applicant sustained injury arising out of and in the course of employment to the neck, the back, and the ears (hearing loss). The WCJ further found that the Request for Authorization (UR) was received by carrier on April 1, 2025; that defendant and EK Health were served with the medical information requested on two occasions prior to the denial letter of April 15, 2025; and that the denial dated April 15, 2025 was untimely (Cal. Code Regs., tit. 8, § 9792.1.9 (e) (5) (F)). He ordered defendant to provide medical treatment in accordance with the RFA issued by Dr. Rasouli dated April 15, 2025.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610
Labor Code section 4610 governs the timeline for utilization review (UR) of a physician's request for authorization (RFA) of medical treatment, requiring decisions within five business days or no more than 14 days from the physician's recommendation date.
Applied to assess timeliness of UR denial and WCAB jurisdiction over untimely UR denials.
From the decision · page 6We highlight several legal principles that may be relevant to our review of this matter. Section 4610, subsection (i)(1) governs the timeline for UR of a physician's RFA of current or future treatment. That subsection provides, in relevant part:
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Dubon II)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Dubon II) holds that an untimely UR decision is invalid and not subject to independent medical review (IMR), and that WCAB has jurisdiction to determine medical necessity in such cases.
Applied to determine WCAB jurisdiction over untimely UR denial and medical necessity determination.
From the decision · page 6In Dubon, supra, we held that: 1. A utilization review (UR) decision is invalid and not subject to independent medical review (IMR) only if it is untimely.
What proof carried it
The evidence the panel weighed, by kind.
The information requested by EK Health was provided by Dr. Rasouli on two prior occasions before the April 15, 2025 denial, supporting the finding of untimeliness of the UR denial.
From the decision · page 5Furthermore, the information requested was also provided to the adjuster and EK Health a second time on October 15, 2024. Dr. Rasouli's office faxed the information to the UR department. The message was sent to the adjuster Lisa Scott at SCIF, the applicant attorney and to the applicant via email. (Exhibit 5) These facts were not disputed by the defendant.
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About this page
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