In a workers’ compensation case, utilization review is an independent review of the medical treatment plan requested by an injured worker’s doctor. The purpose is to determine if the treatment is medically necessary. An independent doctor conducts the review, and generally must make a decision within 5 working days to approve, modify, or deny the treatment.
The steps in utilization review are:
- The treating doctor sends a request for authorization of medical treatment to the insurance company
- The insurance company sends the request to utilization review
- A utilization review doctor approves, modifies, or denies the treatment request
- Utilization review sends the decision to the treating doctor
Utilization review has five working days to approve, modify, or deny the treatment. If a utilization review decision is not made within five working days, it is invalid.
The injured worker must complete the approved treatment by a specified date listed on the approval or modification decision.
If the treatment is denied, an injured worker can file an appeal through a process called independent medical review (IMR).
In this article, our California personal injury lawyers will discuss:
- 1. What is Utilization Review?
- 2. How does the process work?
- 3. What can an injured worker do if a treatment plan is denied?
- 4. Other reasons an insurance company can deny medical treatment
- 5. What does utilization review mean for an injured worker’s medical treatment?
Utilization review is the approval, modification, or denial of the medical treatment recommended by the injured worker’s doctor.1
Medical treatment is one of the benefits an injured worker receives in the California workers’ compensation system.2 Due to insurance companies’ belief that injured workers receive unnecessary treatment, the utilization review system was set up to review medical treatment recommendations.
Filing a claim for workers’ compensation benefits triggers many procedures, including the review of medical treatment.
The process applies to all injuries, including specific injuries and cumulative traumas.
The process applies to out of state care.
Utilization review does not apply to a denied claim. Since the insurance company is disputing whether there is a work injury, there is no need for a treatment plan to be reviewed. All treatment is denied.
An injured worker can only claim mileage reimbursement for treatment approved by utilization review.
Utilization review involves the injured worker’s treating doctor, the insurance company, and the utilization review company.
The request for treatment by the treating doctor is reviewed by a utilization review doctor. The insurance company only has to provide treatment approved by the process.
The request for medical treatment must come from a treating physician. The treating physician is the doctor the injury worker selects to be the primary provider of treatment after a work injury.3
The treating physician must be a:
- medical doctor
who is licensed to practice in California.4
The choice of treating physician depends on the type of injury.
As utilization review is part of the medical treatment process, it begins with an injured worker visiting his or her treating physician. If the doctor believes that treatment is necessary, the review process will begin.
- The treating physician submits a request for authorization (RFA) for medical treatment to the insurance company.5
- The insurance company sends the RFA to utilization review to be evaluated by a doctor working for the utilization review company.6
- The utilization review doctor evaluates the treatment request based on national standards of medical care.7
- Utilization review sends the decision to the insurance company, the injured worker, and the injured worker’s doctor.8
Example: Amy’s doctor, Dr. Quinn, believes she needs eight chiropractic visits for her work injury. Dr. Quinn submits an RFA online to the insurance company. The insurance company forwards this to a utilization review doctor.
The reviewing doctor goes over the request and Amy’s prior medical records and approves the chiropractic treatment.
Utilization review sends the decision to Dr. Quinn, who tells Amy to schedule her chiropractic treatment.
A request for authorization contains all the information the treating doctor believes is necessary to justify a treatment request.
A doctor that submits an RFA must include:
- a diagnosis
- treatment requested
- state guidelines for treatment
- documentation why treatment is necessary9
Many factors go into and complicate the utilization review process and decision.
What is necessary medical treatment?
The utilization review doctor must base his or her decision on:
- guidelines adopted by the administrative director under Labor Code Section 5307.2710
- peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service
- nationally recognized professional standards
- expert opinion
- generally accepted standards of medical practice
- treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious11
Time to complete utilization review
The insurance company has five working days to complete the utilization review process.12 The decision is invalid if it is not completed within five days.13 At that point, only a judge can review the treatment request.14
Example: Kim’s doctor submits a request for a lumbar spine MRI on Thursday, June 6th. The insurance company sends a denial on Friday, June 14th. The denial is late by one working day. The UR decision cannot be used to deny Kim’s treatment.
The insurance company can authorize the treatment or continue to dispute it by asking a judge to make the decision.
Time to complete treatment
Utilization review decisions will give a time frame for the authorized treatment. If the treatment is not completed within the time frame, the treating doctor must submit a new RFA.
Example: In the UR authorization, Erin was given 60 days to complete her physical therapy. Erin only completed four of eight visits within that time. Her doctor must submit a new RFA for four visits.
Modifications of treatment
A utilization review doctor can authorize less treatment than the request made by the treating physician.
Example: Angela’s doctor asked for two months of pain medication, an MRI, and ten physical therapy visits for Angela’s neck injury. The UR doctor only approved one month of pain medication and six physical therapy visits.
Additional information required
If the utilization review doctor cannot decide based on the RFA, he or she can ask the treating doctor to provide more information. If this occurs, the insurance company has 14 working days to make the decision.15
Example: April’s doctor requests surgery for April’s injured shoulder. The utilization review doctor cannot decide without an MRI of April’s shoulder. The treating doctor forwards the MRI.
Instead of five days, UR has 14 days to decide on April’s shoulder surgery.
Insurance company approval of treatment
The insurance company does not have to send a treatment request to utilization review if it agrees to provide the treatment. But an insurance company cannot deny treatment requests on its own.
Example: Ken’s doctor sends the insurance company an RFA for six physical therapy session for Ken’s knee injury. Instead of sending the request to UR, the insurance company approves the treatment.
By approving the treatment, Ken can get quicker treatment, and the insurance company cuts down on paperwork and does not have to pay the UR doctor to review the request.
Automatic approval of some treatment
Some types of treatment requested within the first thirty days of the injury must be authorized.16
However, this only applies in very limited circumstances.
If there is a utilization review denial of treatment, an injured worker can appeal the denial of workers comp benefits.
Absent a change in circumstances, a utilization review denial is valid for twelve months.17 If the same treatment request is submitted again, it must either contain new information or be twelve months after the first request.
An appeal of a utilization review decision is called an independent medical review (IMR).18
IMR does not apply to utilization review decisions that are late.19 Utilization review decisions that are late are invalid and cannot be used to deny treatment.
Every utilization review decision that denies or modifies treatment includes an application for independent medical review.
The injured worker must submit the IMR request within 30 days of the utilization review decision.20
The doctor who reviews the IMR request has 30 days to make a decision.21
There is a database of IMR decisions on the Department of Industrial Relations website.
Medical treatment can also be denied based on:
- A denied injury
- A denied part of body
- The injured worker has reached the 24-visit limit for chiropractic, occupational therapy, or physical therapy22
The utilization review process will slow down an injured worker’s access to medical treatment.
However, insurance companies favor utilization review because it lowers the costs of medical treatment.
An injured worker must know his or her rights at each step in the utilization review process to obtain the right medical treatment.
Call us for help…
For help with filing a workers compensation claim in California or completing workers’ comp forms, contact us. Our firm helps police officers, firefighters and other workers to get compensation for their job-related injuries.
- Cal. Lab. Code § 4610(a).
- Cal. Lab. Code § 4600.
- Cal. Lab. Code § 4600(c).
- Cal. Lab. Code § 3209.3.
- Cal. Code Regs. tit. 8, § 9792.9.1.
- Cal. Lab. Code § 5307.27.
- Cal. Code Regs. tit. 8, § 9792.9.1.
- Cal. Code Regs., tit. 8, § 9785.5.
- Contained in Cal. Code Regs., tit. 8, §9792.2 to 9792.27.23.
- Cal. Lab. Code § 4610.5(c).
- Cal. Lab. Code § 4610(i).
- Dubon v. World Restoration, Inc. (2014) 79 Cal. Comp Cases 313 (en banc).
- Cal. Lab. Code § 4610(g).
- Cal. Lab. Code § 4610(b) – applies to treatment for injuries after 1/1/18 that are accepted as work injuries.
- Cal. Code Regs., tit. 8, § 9792.9.1, subd. (h).
- Cal. Lab. Code § 4610.5.
- Dubon, supra.
- Cal. Lab. Code § 4610.5(h).
- Cal. Lab. Code § 4610.6
- Cal. Lab. Code § 4064.5(c)(1)