The Workers’ Compensation Appeals Board (“WCAB”) recently released a significant Panel decision in Smith v. Marin General Hospital finding that a second timely Utilization Review (“UR”) decision is required when the primary treating physician submits a second Request for Authorization (“RFA”) for treatment within the twelve (12) month period from the UR denial of the first RFA for same.
Pursuant to Labor Code Section 4610(k), a UR denial shall remain effective for twelve (12) months from the date of the denial unless there is a change in the material facts. Here, UR denied the primary treating physician’s first RFA for spinal fusion surgery. Months later, Applicant’s primary treating physician submitted a second RFA for same but checked the box marked “Resubmission – Change in Material Facts” on the RFA. Pursuant to Labor Code Section 4610(k), defendant denied the second RFA as duplicative without submitting it to UR. At that time, the WCAB retained jurisdiction on the medical treatment dispute. The WCAB held that the twelve (12) month period per Labor Code Section 4610(k) was not applicable when defendant received additional supporting information that Applicant’s condition had deteriorated. The WCAB found that it was necessary Applicant receive the requested spinal fusion surgery and defendant failed to timely submit the second RFA to UR.