The California Supreme Court has agreed to review a pivotal appellate decision that could reshape how disputes over ongoing medical care are resolved in the state’s workers compensation system.
In Illinois Midwest Insurance Agency v. Workers’ Compensation Appeals Board (Rodriguez), the 2nd District Court of Appeal held in November that utilization review and independent medical review are the exclusive mechanisms for determining the medical necessity of ongoing treatment, even when such care was previously authorized by an employer or insurer. The decision rejected the longstanding “Patterson doctrine,” which the Workers’ Compensation Appeals Board has relied on to retain jurisdiction over disputes involving the termination of ongoing care.
The high court will consider two questions: whether an exception exists to utilization review and independent medical review exclusivity when an employer seeks to deny previously authorized ongoing treatment, and whether the state appeals board has jurisdiction to hear an employee’s appeal after a denial in those circumstances.
The case arises from claims involving Orlando Rodriguez, who sustained significant head and brain injuries in 2016 and required home health services. Illinois Midwest authorized the care for nearly a year before utilization review denied further treatment in 2019. A workers compensation judge and the appeals board ruled that the insurer could not terminate care absent substantial medical evidence of a change in condition, relying on Jennifer Patterson v. The Oaks Farm.
The appellate court disagreed, concluding that Patterson conflicted with legislative intent to place medical necessity determinations in the hands of medical reviewers, not the appeals board. Independent medical review, the court said, is the sole avenue to challenge utilization review decisions for post-2013 injuries.
The presiding judge of the appeals board’s Los Angeles district office said last week that Rodriguez potentially conflicts with Rivota, a significant 2021 panel decision holding that insurers must show a material change in condition before terminating previously authorized care. The state Supreme Court’s review is expected to resolve that inconsistency statewide.
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