Workers' Comp Treatment Denied in California

First, identify what the letter decided

A letter denying a particular treatment is different from a letter denying the entire workers' compensation claim. Utilization Review, or UR, addresses a physician's treatment recommendation. Independent Medical Review, or IMR, is the process for eligible UR decisions that deny or modify treatment based on medical necessity.

Read the treatment description, reason for the decision, and review instructions together. Save every page, the IMR application, and the envelope, email, or portal record. A date printed on a letter and the date it was formally served are not necessarily the same.

Labor Code section 4610.5 describes IMR's role. If the insurer disputes the entire claim or liability for the treatment for another reason, keep that separate notice too. The denied-claim guide addresses the broader claim question.

Check the IMR request period against the complete notice

Under Rule 9792.10.1, the general request period is 30 days after service of the written UR determination. A 10-day period applies only when the decision solely denies or modifies a request for a drug on the MTUS Drug List. A reference to a prescription somewhere in the medical file does not by itself establish that exception.

These are rules for checking a notice, not a reason to put it aside. Preserve the original documents and ask for help promptly if the decision or service information is unclear. Do not assume that an informal discussion with the insurer replaces the IMR application.

Prepare the request and keep a submission record

The request uses the current DWC Form IMR with a copy of the written decision denying or modifying treatment. At filing, the employee also provides the claims administrator with a copy of the signed form, without a copy of that written decision. Follow the current official form and rule for the filing method and destination.

Keep a copy of the completed application and evidence showing when and how it was sent. Ask the treating physician for the Request for Authorization and records relevant to the reason given in UR. A short timeline can help separate the request, decision, filing, and later notices.

• The complete UR determination and IMR application.
• The treating physician's requested treatment and supporting notes.
• Relevant test results, therapy records, and medication information.
• Service records and any separate liability notice.
• Copies of submissions and any later request for information.

Understand who supplies the medical records

The claims administrator has required record-submission duties after IMR assignment. The worker, representative, and other eligible participants can also provide supporting information under Rule 9792.10.5. The treating physician can help explain why the requested care is medically necessary.

The rule also addresses newly developed or discovered relevant medical records and additional information requested by the independent review organization. The applicable submission and service requirements matter. Keep later requests with the original file and respond according to the specific instructions and rule.

A determination has a different clock

The time to request IMR is separate from the organization's time to decide it. Under Rule 9792.10.6, a regular determination is due within 30 days after receipt of the application and supporting documentation. A decision solely about a listed MTUS drug has a five-business-day determination period. Qualifying expedited review has its own requirements. Limited extensions require administrative approval.

The IMR process guide explains these stages and the record-submission roles in more detail. If the treating physician identifies an imminent and serious threat to health, review the expedited-request requirements with the physician rather than assuming the ordinary process is appropriate.

If the IMR determination does not resolve the problem

An IMR determination is binding when issued. A later WCAB petition is a separate, limited procedure under Labor Code section 4610.6 and Rule 10575. Rule 10575 provides a 30-day period after service of the determination, including an ineligibility determination. It is not a general opportunity to ask a judge to reconsider medical necessity.

Keep the determination, proof of service, and documents identifying the unresolved issue. A later treatment request, authorization problem, or challenge to the determination can raise different questions. The actual records determine which question needs attention.

The current official application also explains mailing-related additions to filing time. Check the form, service method, and instructions before calculating the deadline for a specific notice.

Organize the documents before asking for help

The workers' compensation consultation checklist can help organize notices, medical records, and a short timeline. If a provider sent a bill after a denial, use the separate medical-billing guide to identify the document and payment issue.

Yazdchi Law is based in Palmdale. Eman Yazdchi is a Certified Specialist in Workers' Compensation Law, California Board of Legal Specialization, State Bar of California. Call (661) 273-1780 or use the contact form to ask whether the firm can assess a California workers' compensation matter.

Official IMR sources

• IMR request rules
• Medical-record submissions
• Determination standards and timing
• Petition after an IMR determination
• Current official DWC Form IMR (PDF)