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Constitutionality of workers comp medical review process upheld

Posted On: Oct. 29, 2015 12:00 AM CST

Constitutionality of workers comp medical review process upheld

California's 1st District Court of Appeal has upheld the constitutionality of the state's independent medical review process for injured workers.

Workers compensation reforms that took effect in 2004 created the utilization review process, under which a request for treatment must be approved by a claims adjuster unless a physician determines it medically unnecessary, court records show. And while injured workers can challenge denials for treatment, employers can't challenge approvals.

Additional reforms took effect in 2013, establishing the independent medical review process to resolve injured workers' challenges to utilization review decisions, according to records.

Frances Stevens, who fractured her right foot in October 1997 while working as a magazine editor for San Francisco-based Outspoken Enterprises Inc., argued that the independent medical review process is unconstitutional, as it violates requirements that workers comp decisions be subject to review, records show.

A workers comp judge in May 2013 determined that Ms. Stevens, who was diagnosed in 1999 with complex-regional-pain syndrome in both feet, was permanently totally disabled, according to records. She uses a wheelchair as a result of the pain and, in turn, has developed low-back and bilateral-shoulder pain, as well as depression.

While Outspoken Enterprises' workers comp insurer, State Compensation Insurance Fund, didn't dispute that Ms. Stevens suffers from pain and other ailments, her requests for a home health aide, Ativan, Flexeril, diolofenac cream and hydrocodone were denied, records show.

Ms. Stevens appealed the independent medical review decision to California's Workers' Compensation Appeals Board, saying the statute violates her rights to due process, according to records. A workers comp judge concluded that the board had no jurisdiction to consider the constitutionality of the statute.

She then filed a petition for a writ of review with California's 1st District Court of Appeal in San Francisco.

The court on Wednesday ruled that “California's scheme for evaluating workers' treatment requests is fundamentally fair and affords workers sufficient opportunities to present evidence and be heard.”

The ruling notes that the independent medical review process “gives workers, but not employers, a second chance to obtain a decision in their favor.”

However, the matter has been remanded to the board to determine whether Ms. Stevens' request for a home health aide was denied without authority, as “the care is authorized under the (Medical Treatment Utilization Schedule).”