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Medical treatment is subject to Utilization Review which can approve or deny the treatment. Under the DUBON case, the UR must be timely, otherwise the WCAB has jurisdiction to award treatment based on substantial medical evidence. Another way to get around a UR denial of care is if the PTP submits a 2nd RFA based on a documented change in the facts material to the basis of the UR. Normally you have to wait 12 months to submit another RFA for the same denied treatment. However..., once the PTP submits another RFA based on a change of material facts, the adjuster must send it to UR or risk blowing the UR timeline. This was the case in Smith v. Marin General Hospital, 2020 Cal.Wrk.Comp.P.D.LEXIS__, wherein a fusion surgery was denied by both UR and IMR, but then applicant’s condition worsened resulting in new diagnosis of cauda equine syndrome. A new RFA was submitted indicating a Resubmission-Change in Material Facts. The WCAB held the adjuster’s failure to send this 2nd RFA to UR gave the WCAB jurisdiction to award the surgery. Under Wyant v. American Medical Response(2017) 83 CCC 946, if the first RFA was not clear that conservative care had failed, the 2nd RFA explaining the ineffective conservative care qualified as a change in material facts to support the UR approval of surgery. See more

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