California Workers Compensation / Independent Medical Review/ Denied Treatment

It is not unusual for an insurance company to deny treatment in a workers' compensation case. It is important to know how to handle a denial of treatment request. Generally, where liability for a work-related injury has been accepted, a treating physician will request authorization for certain treatments from the insurance company. Upon receipt, the insurance company will normally engage their Utilization Review process to determine whether the treatment being requested by the treater on behalf of an injured worker is medically necessary. If the insurance company's Utilization Review entity determines that the requested treatment is not medically necessary, it will issue a notice of denial and/or modification. Along with Notice of the denial or modification, the labor code requires the service of an Independent Medical Review application.

Independent Medical Review is conducted by an unbiased entity- Maximus Federal Services- to test the correctness of the Utilization review denial or modification. The change in laws created by Senate Bill 863 renders the Independent Medical Review process the exclusive remedy to determine treatment issues. In other words, if the Utilization Review process is PROCEDURALLY proper, an injured worker must go through the Independent Medical Review process in order to resolve treatment issues. This is when the aid of an attorney who is familiar with the workers' compensation process becomes important. There are time limits that coincide with the Independent Medical Review Process. In addition, an attorney can aid an injured worker in making the best case in front of the Independent Medical Review evaluator to seek the approval of the denied or modified treatment.

If you are an injured worker and the insurance company has denied certain treatments requested by your doctor, please call our office to discuss your matter. Time is of the essence in these types of issues. We are here to help. Please call (714) 360-0100 to speak with one our attorneys.