Workers’ Comp Medical Treatment Disputes in California
Getting hurt at work is hard enough. Having the insurance company deny the surgery, therapy, or medication your doctor recommends can stall your recovery. Here’s how California workers’ comp treatment approval works, and how to fight back when care is denied or delayed.
How Medical Treatment Works in California Workers' Comp
If your work injury is covered, the insurance company must pay for all reasonable and necessary medical treatment to cure or relieve its effects. That can include doctor visits, physical therapy, imaging, surgery, medication, and other care. The catch is that most treatment has to be approved before you receive it, and that approval process is where many disputes begin.
It starts with your treating doctor. When the doctor recommends treatment, they send the insurer a Request for Authorization (RFA). The insurer then reviews the request against the state's treatment guidelines, called the Medical Treatment Utilization Schedule (MTUS), and approves, modifies, or denies it.
Choosing Your Doctor: MPNs and Predesignation
Many employers use a Medical Provider Network (MPN), a list of doctors approved to treat workers' comp injuries. If your employer has one, you generally must treat within it, but you usually have the right to choose a different doctor in the network after your first visit, and to ask for a second and third opinion within the MPN if you disagree with a diagnosis or treatment plan.
If you predesignated your own personal doctor in writing before you were injured, and you meet the requirements, you may be able to treat with that doctor instead of one in the MPN.
What Is Utilization Review?
Utilization review (UR) is the process the insurance company uses to decide whether a requested treatment is medically necessary (Labor Code section 4610). A reviewing doctor, who usually never examines you, compares the request with the treatment guidelines.
- Standard requests: UR generally must decide within 5 business days of receiving the information it needs, and no later than 14 days from the request.
- Urgent requests: when waiting would seriously threaten your health, an expedited decision is generally due within 72 hours.
- The result: the treatment is approved, modified (approved in part), or denied, and you and your doctor receive a written decision.
Common Reasons Treatment Gets Denied
- "Not supported by guidelines": the reviewer says the request falls outside the MTUS.
- Missing information: the doctor's request didn't include enough records or explanation.
- Prior treatment "failed": the reviewer says earlier therapy didn't show enough improvement to continue.
- Too many sessions: physical therapy, chiropractic, or acupuncture visits exceed the guideline limits.
- Medication limits: certain drugs, especially pain medications, are restricted under the state's drug formulary.
- Body part not accepted: the insurer disputes that the body part being treated is part of the claim. This is a different kind of dispute, handled differently from UR.
How to Challenge a Denial: Independent Medical Review
If UR denies or modifies a treatment request because it says the treatment isn't medically necessary, the way to challenge it is Independent Medical Review (IMR) (Labor Code section 4610.5).
- Watch the deadline. You generally have 30 days from service of the UR decision to request IMR. The application form comes with the denial letter.
- Submit the request to the state's IMR organization, along with the denial letter.
- Make sure the records get there. The reviewer decides based on the medical records it receives, so a strong report from your doctor explaining why the treatment is needed matters.
- Get the decision. IMR decisions are generally issued within about 30 days of receiving the records, or within days for expedited cases.
IMR decisions are difficult to overturn. An appeal to the Workers' Compensation Appeals Board is allowed only on narrow grounds, such as fraud, a conflict of interest, bias, or a plainly mistaken fact. That's why the request your doctor submits, and the records sent with it, matter so much.
Treatment Disputes That Aren't Handled by IMR
Not every medical dispute goes through UR and IMR. If the insurer says your injury, or a particular body part, isn't covered at all, that's a question of whether the claim is compensable. It's handled through the Workers' Compensation Appeals Board, often with a Qualified Medical Evaluator (QME). See our page on denied and disputed claims. While a claim is still under investigation, the employer generally must authorize up to $10,000 in treatment.
What If Treatment Is Delayed or Never Answered?
If the insurer doesn't complete UR within the required time, its decision may be considered untimely, and the dispute over the treatment can be decided by a workers' compensation judge instead. Delays can also affect your temporary disability and your recovery, so keep copies of every request, denial, and letter, and note the dates you received them.
Other Medical Benefits You May Be Owed
- Mileage and travel reimbursement for trips to medical appointments, therapy, and pharmacies related to your injury
- Medication prescribed for the work injury
- Medical equipment such as braces or mobility devices when they're medically necessary
- Future medical care, which can stay open after your case resolves, depending on how it settles. This is especially important if you have a permanent disability.
Medical Treatment FAQ
How long does the insurance company have to approve treatment?
For a standard request, utilization review generally must decide within 5 business days of receiving the information it needs, and no later than 14 days from the request. Urgent requests are generally decided within 72 hours.
How long do I have to request Independent Medical Review?
Generally 30 days from service of the utilization review decision that denied or modified the treatment. The IMR application form should come with the denial letter.
Can I change my workers' comp doctor?
Usually, yes. If your employer uses a Medical Provider Network, you can generally choose a different doctor within the network after your first visit and ask for second and third opinions. If you predesignated a personal doctor before your injury, you may be able to treat with that doctor.
What if IMR upholds the denial?
IMR decisions can be appealed only on narrow grounds, such as fraud, a conflict of interest, bias, or a clear mistake of fact. In many cases, the better path is for your doctor to submit a new, stronger request with additional information.
Does workers' comp pay mileage for medical appointments?
Generally, yes. Reasonable travel expenses for treatment and medical evaluations related to your work injury can be reimbursed. Keep a record of each trip's date, destination, and miles.
For more answers, visit our workers' comp FAQ page.
Treatment denied or delayed?
Our Long Beach office helps injured workers across Southern California fight utilization review denials and get the care they need. Free consultation, and no fee unless we recover benefits for you.
Schedule a Free Consultation Call (714) 202-7182
