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3rd DCA to Review WCAB's Order for Home Modifications for Worker after UR Denial

  • State: California
  • Topic: Top
  • - Popular with: Legal
California's 3rd District Court of Appeal has agreed to weigh in on whether a workers' com…

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Anonymous Nov 3, 2016 a 7:58 am PDT

Did I read this story correctly? Was the request in question the need for a wheelchair or the bathroom remodel to accommodate the wheelchair that I assume was already approved previously since it was provided to the injured worker? Wouldn't that be the same as a reviewer reversing a prior approval for a wheelchair when it was not in question in the first place in order to deny the bathroom remodel?

Anonymous Nov 21, 2016 a 10:49 am PST

Unbelievable this was being denied in the first place.

Anonymous Nov 3, 2016 a 7:58 am PDT

How is a bathroom modification to allow a wheelchair to get in a medical issue of treatment? There is no treatment involved. It is a question of access to a bathroom. UR has no place in it

Anonymous Nov 3, 2016 a 7:58 am PDT

UR has it's tentacles into everything. It should be used to decide on what form of treatment is acceptable per MTUS. In my opinion it should not be used to determine if a doctor to doctor referral within an MPN is necessary. That is not a "treatment" issue per se, but an "evaluation" issue. That is how doctors communicate with each other, if something is outside their expertise. Isn't that how MPNs work? If the consultant then requests some specific treatment, then UR comes into play. What about testing? Is that "treatment"?
Why should UR be involved, if I need an MRI to make a diagnosis. That is not "treatment" In my opinion, and I know others will argue, UR/IMR is misused and perhaps the 3rd DCA can clarify what it is to be used for.

YORK RISK SERVICES GROUP Nov 3, 2016 a 7:58 am PDT

The only reason I would find the need for modifications questionable in this case is the fact that the claimant is able to walk the distance from the door to the toilet, shower or sink. It's a matter of a few steps. Yes, he has the propensity for fainting, but if it is severe enough for him to be unable to walk the few steps, then he would need 24 hour care and would be unable to do anything without assistance.

Julie A. Parkin Nov 3, 2016 a 7:58 am PDT

I have a lot of support for UR but when I see things like this it just throws a wrench at defendants. This is a case that should have never gotten this high or noticed. Defendants really need to look at the battles they want to fight. Not modifying the claimant's bathroom could lead to repurcussions down the road for everyone. The argument could be made that this would fall under other medical issues not addressed under UR that would have to go the AME/ QME route. See below. However, many AA's don't want to open the door to another evaluation, as it may just throw a wrench into their gears by having a doctor evaluate a questionable claimant. They don't want to pollute the pond by risking a PQME evaluation that may just find things different then the treating doctors. What are we fighting for here based on the available information in this case? Just modify the bathroom and move on.

4062. (a) If either the employee or employer objects to a medical determination made by the treating physician concerning any medical issues not covered by Section 4060 or 4061 and not subject to Section 4610, the objecting party shall notify the other party in writing of the objection within 20 days of receipt of the report if the employee is represented by an attorney or within 30 days of receipt of the report if the employee is not represented by an attorney. These time limits may be extended for good cause or by mutual agreement. If the employee is represented by an attorney, a medical evaluation to determine the disputed medical issue shall be obtained as provided in Section 4062.2

Ashleigh Rivera Nov 3, 2016 a 7:58 am PDT

Great article, well written.

Anonymous Nov 21, 2016 a 10:49 am PST

I was reviewing IMR determinations and found a few gym memberships that were denied by stating it is not "medical treatment". Either is an what does an applicant do with this type of denial? Not as big as the above story, however denied due to it "not being medical treatment".


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