What the panel ordered
Defendant's Petition for Reconsideration is denied.
Defendant filed a Petition for Reconsideration of the WCJ's Findings and Award dated June 21, 2024, which was timely acted upon by the Appeals Board on October 11, 2024.
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 Request for Authorization (RFA) for expedited utilization review was timely submitted and met the criteria for expedited review due to the applicant's serious traumatic brain injury and associated impairments posing an imminent and serious threat to health. The UR decision was untimely, and the requested supported living program was reasonably required medical treatment. Therefore, the defendant's petition contesting the timeliness and medical necessity was denied.
From the decision · page 3Turning to the merits, the Opinion and Decision and the Report explain why the March 22, 2024 report of primary treating physician Henry Koh, M.D. meets the criteria for expedited review pursuant to Labor Code section 4610(i)(3) and Administrative Rule 9792.9.1(c)(4) (Cal. Code Regs., tit. 8, § 9792.9.1, subd. (c)(4).) The Petition appears to argue that the criteria was not met because Dr. Koh did not use the specific language of the statute and/or regulation in explaining why expedited review was necessary. However, the statute and regulation only require that the request or accompanying report document the need for expedited review, not that any specific language be utilized or that the substantiation occur in any specific place of the request or accompanying medical report. Accordingly, we will deny defendant's Petition for the reasons stated in the Opinion on Decision and Report quoted below. We have omitted the discussion in the Report of applicant's case manager's letter of May 6, 2024 as evidence that applicant's request for expedited review was properly supported. Since this letter was drafted after the submission of the RFA, and was not submitted to the defendant as part of the UR process, it cannot be a basis for stating that the request for expedited review was proper. However, Dr. Koh's report itself contains the basis for the necessity of expedited review.