Proper Deferral of Utilization REVIEW

Millette v. 81 Grand holdings, Inc. (writ denied) is a good overview of what is necessary for a proper deferral of utilization review.  In this case, the Applicant sustained a cervical spine injury and underwent surgery. Post-operatively, various treatment modalities were requested, including home care, a Foley catheter, a power wheel chair, and a urological consult, which the defendant deferred on the basis that causation was in dispute.  At expedited trial, the WCJ awarded the treatment reasoning that 8 CCR §9792.9.1(b) requires “a clear, concise and appropriate explanation of the reason for the claims administrator’s dispute of liability for either the injury, claimed body part or parts, or the recommended treatment.”  The defendant filed for reconsideration arguing that this order would bypass the UR process.  However, the WCJ stated in his report and recommendation, that he relied on 8 CCR §9792.9.1(b)(1)(D) which requires a plain language statement in the deferral and that the dispute resolution process is through the WCAB.