What the panel ordered
Reconsideration granted to amend findings to confirm the November 16, 2023 UR determination was valid and final; otherwise, the May 28, 2025 WCJ decision is affirmed, ordering defendant to comply with the UR determination and admitting trial exhibits into evidence.
Defendant sought reconsideration of the May 28, 2025 Findings of Fact and Orders regarding the Utilization Review determination and the WCJ's jurisdiction to alter it. The WCJ had denied defendant's motion to vacate the UR determination and ordered authorization of treatment. The WCAB granted reconsideration, amended findings to reflect the UR determination was valid and final, and otherwise affirmed the WCJ decision.
This docket was decided more than once. Shown here is the latest released decision; we also hold January 21, 2025.
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 properly exercised authority under Labor Code section 4604 to order compliance with a valid UR determination, and the UR determination was final and binding under section 4610.5(f)(1).
From the decision · page 2On November 12, 2024, defendant petitioned for reconsideration of the WCJ's decision. On January 21, 2025, we denied defendant's petition. (Opinion and Order Denying Petition for Reconsideration, dated January 21, 2025.) On April 28, 2025, the parties proceeded to trial and framed for decision the issue of "[j]urisdiction of WCJ to determine need for medical care as requested by Dr. Elliott Block as set
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The November 16, 2023 Utilization Review determination certified the medical necessity of the treatment request and was final and binding under Labor Code section 4610.5(f)(1).
Favours Applicant prevailed
This fact established the validity and finality of the UR determination, supporting the WCJ's order for defendant to comply with the treatment authorization.
From the decision · page 6Every employer is required to establish a utilization review process for screening, reviewing, and deciding on treatment recommendations that are made by an employee's physician. (§ 4610, subds. (a) & (b).) Any decision to modify, delay, or deny a request for medical treatment for a work-related injury must be made by a licensed physician pursuant to a utilization review process. (§ 4610, subd. (e).) The utilization review process must be governed by written policies and procedures that are based on medical necessity and consistent with the "schedule for medical treatment utilization" adopted pursuant to section 5307.27.2 (§ 4610, subd. (c).) The employer must make its decision on treatment in a timely fashion, but not to exceed five working days from receipt of the information necessary to make the determination, and not more than 14 days from the date of the request by the employee's physician. (§ 4610, subd. (g)(1).) If the utilization review approves the requested treatment, the determination is final and the employer may not challenge it. (§ 4610.5, subd. (f)(1).)
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.
Diagnosed traumatic brain injury with post-traumatic headaches, mood disorder, and multi-trauma; requested extensive residential transitional living program and medications.
From the decision · page 2On November 8, 2023, treating physician Elliott Block, M.D. submitted a report diagnosing a traumatic brain injury with post-traumatic headaches, a mood disorder, and "multi-trauma." (Ex. 10, Report and RFA of Elliott Block, M.D., dated November 8, 2023.) Dr. Block submitted a corresponding RFA for medications and for a "transitional living center residential program post acute rehabilitation to include PT, OT, ST, and neuropsychology up to 6 hours per day, 24-hour nursing oversight, [and] medical management." (Id. at p. 4.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code, § 5909
Labor Code section 5909 regarding timely action on petitions for reconsideration.
The WCAB acted within the 60-day period to timely decide the petition for reconsideration.
From the decision · page 4Under section 5909(a), the Appeals Board must act on a petition for reconsideration within 60 days of transmission of the case to the Appeals Board. Transmission is reflected in Events in the Electronic Adjudication Management System (EAMS). Specifically, in Case Events, under Event Description is the phrase "Sent to Recon" and under Additional Information is the phrase "The case is sent to the Recon board."
Labor Code section 4610 and 4610.5 regarding utilization review process and finality of UR determinations.
The UR process must be timely and based on medical necessity; a certified UR determination is final and not subject to employer challenge.
From the decision · page 6Every employer is required to establish a utilization review process for screening, reviewing, and deciding on treatment recommendations that are made by an employee's physician. (§ 4610, subds. (a) & (b).) Any decision to modify, delay, or deny a request for medical treatment for a work-related injury must be made by a licensed physician pursuant to a utilization review process. (§ 4610, subd. (e).) The utilization review process must be governed by written policies and procedures that are based on medical necessity and consistent with the "schedule for medical treatment utilization" adopted pursuant to section 5307.27.2 (§ 4610, subd. (c).) The employer must make its decision on treatment in a timely fashion, but not to exceed five working days from receipt of the information necessary to make the determination, and not more than 14 days from the date of the request by the employee's physician. (§ 4610, subd. (g)(1).) If the utilization review approves the requested treatment, the determination is final and the employer may not challenge it. (§ 4610.5, subd. (f)(1).)
Lab. Code, §§ 5300, 5301, 5304, 4604
Labor Code sections 5300, 5301, 5304, and 4604 regarding WCAB authority to enforce compensation and medical treatment disputes.
The WCAB has authority to enforce valid UR determinations and resolve medical treatment controversies not subject to IMR.
From the decision · page 8Finally, we note that the Labor Code expressly vests the Appeals Board with the authority for "the enforcement against the employer or an insurer of any liability for compensation imposed
What proof carried it
The evidence the panel weighed, by kind.
The UR determination certified the medical necessity of the treatment request and was final and binding under Labor Code section 4610.5(f)(1).
From the decision · page 6Every employer is required to establish a utilization review process for screening, reviewing, and deciding on treatment recommendations that are made by an employee's physician. (§ 4610, subds. (a) & (b).) Any decision to modify, delay, or deny a request for medical treatment for a work-related injury must be made by a licensed physician pursuant to a utilization review process. (§ 4610, subd. (e).) The utilization review process must be governed by written policies and procedures that are based on medical necessity and consistent with the "schedule for medical treatment utilization" adopted pursuant to section 5307.27.2 (§ 4610, subd. (c).) The employer must make its decision on treatment in a timely fashion, but not to exceed five working days from receipt of the information necessary to make the determination, and not more than 14 days from the date of the request by the employee's physician. (§ 4610, subd. (g)(1).) If the utilization review approves the requested treatment, the determination is final and the employer may not challenge it. (§ 4610.5, subd. (f)(1).)
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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