Detailing the medical treatment dispute resolution process created by Labor Code Sections 4610 and 4062, the California Supreme Court has issued its decision in SCIF v. WCAB (Sandhagen).

In Sandhagen, Applicant’s physician requested an MRI. Defendant denied authorization but failed to issue a timely utilization review (UR). The case proceeded to expedited hearing. The untimely UR was excluded from evidence. Defendant was ordered to provide the requested treatment. The matter proceeded to the WCAB, which issued an en banc decision allowing Defendant to circumvent the UR protocol. The Court of Appeal agreed, and the case was appealed to the Supreme Court.

Noting that authorizations of treatment do not require UR, the Supreme Court in SCIF v. WCAB (Sandhagen) concluded that any denial of medical treatment must undergo Labor Code Section 4610 utilization review. Stated differently, before an employer can deny liability for medical treatment, it first must conduct a UR of the request. If a UR is not conducted, the employer cannot submit the dispute to a QME.

The Court observed that employers cannot “opt out” of the UR process. The language of the statutes clearly “indicates the Legislature intended for employers to use the utilization review process when reviewing and resolving any and all requests for medical treatment.”  Adding to this interpretation, the language of section 4062 “simultaneously precludes employers from using its provisions to object to employees’ treatment requests but permits employees to use its provisions to object to employers’ decisions regarding treatment requests.” [italics in original.]

While authorized treatment does not require UR, the Court concluded “section 4062 is not available to employers as an alternative avenue for disputing employees’ requests for treatment.”