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In Jose Dubon v. World Restoration Inc., the full California Workers' Compensation Appeals Board ruled unanimously in February that it must decide a dispute over a worker's utilization review, rather than having it decided through the independent medical review process established by California's most recent workers comp reform law.
The appeals board ruled there were “procedural defects” in a utilization review ordered by the California State Compensation Insurance Fund and that such claims can't be resolved in independent medical reviews.
An independent medical review “solely resolves disputes over the medical necessity of treatment requests,” according to the appeals board. “Issues of timeliness and compliance with statutes and regulations governing (utilization review) are legal disputes” within its jurisdiction, the appeals board ruled.
In May, the board agreed to reconsider its decision in Dubon after the state fund argued that independent medical reviews apply to “any dispute” over a workers comp review under California law. The board has not made a final ruling.
California's workers compensation reforms have produced an unexpected surge in independent medical reviews, but experts and employers say more time is needed to see whether the changes reduce costs and claims management delays.