Utilization Review (UR) is the process by which a defendant, through a licensed physician it employs or with whom it contracts, reviews the treatment recommendations of an injured employee’s treating physician and then decides whether to approve, modify, delay, or deny authorization for the treatment based on medical necessity. (Labor Code 4610). The only exception is if the defendant challenges whether the industrial injury caused or contributed to the need for surgery since the cause of a need for treatment is not an issue subject to UR. (Rule 9792.6(s)).
Implicit in establishing UR was the legislature’s intention to create an expeditious and inexpensive method to assess a treating physician’s medical treatment recommendations. The California Supreme Court weighed in on the issue in Sandhagen concluding that the Legislature intended utilization review to be an employer’s only avenue for resolving an employee’s request for treatment (State Compensation Insurance Fund v Workers’ Compensation Appeals Board (Sandhagen) 44 Cal. 4th 230).
The question, though, is what constitutes a “request for treatment” or a “treatment recommendation”?
AD Rule 9792.6(o) provides:
Request for authorization means a written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment. An oral request for authorization must be followed by a written confirmation of the request within seventy-two (72) hours. Both the written confirmation of an oral request and the written request must be set forth on the Doctor’s First Report of Occupational Injury or Illness, Form DLSR 5021, section 14006, or on the Primary Treating Physician Progress Report, DWC Form PR-2, as contained in section 9785.2, or in narrative form containing the same information required in the PR-2 form. If a narrative format is used, the document hall be clearly marked at the top that it is a request for authorization.
The Workers’ Compensation Appeals Board, in its en banc decision in Cervantes v El Aguila Food Products, Inc. 74 CCC 1336, explained that Rule 9792.6(o) is part of the “Utilization Review Standards” adopted by the Administrative Director and that the Rule recognizes that claims adjusters routinely receive numerous medical reports from treating physicians concluding that, if a treating physician seeks authorization through a narrative report, the narrative report must clearly state at the top that authorization is being requested. (Cervantes, supra p.1353).
At footnote 19, “narrative report” was interpreted by the Board to mean any medical report other than the Doctor’s First Report of Occupational Injury or Illness (DLSR Form 5021) or the Primary Treating Physician Progress Report (DWC Form PR-2) since the PR-2 already has a check box for “request for authorization” (AD Rule 9785.2.).
Therefore, unless a PR-2 has the “request for authorization” box checked or a narrative report is headed “Request for Authorization,” it does not constitute a “request for treatment” or “treatment recommendation” that requires utilization review.