Illinois Midwest Insurance Agency, LLC v. Workers’ Compensation Appeals Board and Orlando Rodriguez

Summary

The California Court of Appeal held that the Workers’ Compensation Appeals Board lacked jurisdiction to resolve a dispute over the medical necessity of ongoing home health care after a utilization review denial. The court concluded that, for injuries and utilization review decisions governed by the post-2013 statutory scheme, disputes over medical necessity must proceed through utilization review and independent medical review, rather than an extra-statutory WCAB proceeding. The court rejected Patterson v. The Oaks Farm to the extent it recognized a contrary exception and annulled and remanded the WCAB decision.

Holdings

1. The WCAB lacked jurisdiction to decide whether Rodriguez’s requested home health care was medically necessary because Labor Code section 4610.5 requires disputes over applicable utilization review decisions to be resolved through independent medical review.
2. There is no statutory ongoing-treatment exception allowing the WCAB to decide the medical necessity of subsequent treatment requests outside the utilization review and independent medical review processes.
3. Patterson is rejected to the extent it established a contrary rule for injuries or medical-necessity determinations arising after the 2013 reforms; it cannot authorize WCAB review of a timely utilization review denial subject to section 4610.5.

Questions Presented

1. Whether the WCAB had jurisdiction to decide the medical necessity of home health care after a timely utilization review denial.
2. Whether ongoing or continual treatment previously authorized by an employer is exempt from the statutory utilization review and independent medical review procedures.
3. Whether Patterson v. The Oaks Farm remains valid authority for an ongoing-treatment exception after the 2013 statutory reforms.

Disposition

other