By now we are all familiar with the Sandhagen process for obtaining certification for medical treatment. There has been some question, however, as to an applicant’s ability to proceed to a hearing following the UR determination. A recent WCAB panel decision has shed some light as to the process following a delay, modification or denial of treatment through Utilization Review.
Although the Labor Code and Sandhagen provided an outline for pursuing medical treatment authorization, some applicant’s and their attorneys have elected to forgo the objection process under Labor Code section 4062 and proceed directly to an expedited hearing placing the trial court in a position to determine the appropriate medical course between the treating physician’s determination and that of the UR physician. The WCAB by way of its holding in Gregory Wills v. Waste Management finds the mandatory language of Labor Code sections 4610 and 4062 to be applicable to employees just as it is for employers. By way of this holding, for an applicant to obtain review of a UR determination delaying, modifying or denying medical treatment, it requires them to object pursuant to Labor Code section 4062 and utilize the process under Labor Code section 4062.2 if represented or Labor Code section 4062.1 if unrepresented. They may not proceed directly to an Expedited Hearing. The holding essentially enforces the process of the Labor Code ensuring a review by a Agreed Upon or Panel Qualified Medical Evaluator for any disputed medical issue.
Although only a panel decision, the holding is felt to be in line with the mandates of the Labor Code and the decision of Sandhagen. The process should reduce the number of expedited hearing requests on treatment issues, but will shift the costs to the medical legal process. By utilizing the medical legal process, it is likely a number of issues that would have been presented by way of hearing will be resolved without the need for further court intervention. Ultimately, the treatment recommendation will have been given adequate review by multiple physicians and result in a treatment protocol without need for court intervention, which should lead to reduced costs. A Petition for Reconsideration of the panel decision is on file.