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Special Report: DWC Clarifies Mandatory Use of Request for Authorization Form and Requirements for Complete RFA

Posted by:  Sure S. Log
Topics: Utilization Review Request for Authorization CCR 9792.9.1 narrative report incomplete RFA completed request claims administrator UR process DWC Form RFA CCR 9792.6.1

The utilization review (UR) process begins when a claims administrator receives a completed request for authorization from a treating physician. Under the updated UR regulations that became effective April 1, 2026, California Code of Regulations (CCR), Title 8, § 9792.6.1(u) defines what constitutes a valid "request for authorization," and specifies the conditions under which a request is deemed "completed" for purposes of triggering the UR clock. CCR 9792.9.1(b) addresses the claims administrator's obligations on receipt of a request that does not meet the definition of a completed request.

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WCAB Clarifies Analysis for QME Replacement After Relocation

Posted by:  Sure S. Log
Topics: QME replacement QME LC 4062.3 reevaluation multifactorial analysis travel reasonable geographic distance CCR 34 geographic distance same evaluator

Once a qualified medical evaluator (QME) has been selected in a represented case, California Code of Regulation (CCR) 34(b) explains that any subsequent evaluation may be performed at a different medical office of the selected QME if that office is listed with the medical director and is "within a reasonable geographic distance from the injured worker's residence." Labor Code § 4062.3(k) further directs that, after a medical evaluation is prepared, the parties "shall utilize the same medical evaluator who prepared the previous evaluation to resolve the medical dispute" to the extent possible. Together, those provisions reflect a strong preference for continuity of the medical-legal evaluator, and they set the framework for disputes that arise when a QME relocates his or her practice.

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WCAB Clarifies Valid Objection to Treating Physician Report Under LC 4061

Posted by:  Sure S. Log
Topics: PTP Permanent Disability LC 4062.2 Primary Treating Physician QME panel LC 4062 valid objection QME panel validity LC 4061 objection treating physician report future medical care

In accepted cases, Labor Codes 4061 and 4062 establish the procedures by which parties may dispute a medical determination made by a primary treating physician (PTP) and, when the employee is represented by an attorney, obtain a comprehensive medical evaluation through the qualified medical evaluator (QME) panel process under LC 4062.2. Under LC 4061(b), a valid objection may be raised to a PTP's medical determination "concerning the existence or extent of permanent impairment and limitations or the need for future medical care." Under LC 4062(a), objections to medical determinations may be raised to issues not covered by LC 4061 (for example, ongoing temporary disability, body parts injured, work restriction).

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SPECIAL REPORT: DWC Overhauls Utilization Review Regulations

Posted by:  Sure S. Log
Topics: Utilization Review UR 30-day exemption regulations penalties drug formulary administrative regulations utilization review investigations

Effective April 1, 2026, the Division of Workers’ Compensation (DWC) adopts a comprehensive and extensive set of new regulations governing utilization review (UR), independent medical review (IMR) and physician reporting. The regulations are available on the DWC's rulemaking page.

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Significant Panel Decision Clarifies Commutation of Attorney Fees from Lifetime Awards

Posted by:  Sure S. Log
Topics: Permanent Disability permanent total disability jurisdiction to enforce side of the award horizontal commutation LC 5803 LC 5804 continuing jurisdiction life pension commutation lateral commutation

Permanent disability benefits often are commuted to pay the fees of an applicant's attorney. Usually, the Workers' Compensation Appeals Board (WCAB) will order attorney fees to be commuted from the "far end" of the permanent disability award. That means the WCAB will commute a sufficient number of payments at the end of the award so that a lump sum can be issued to the attorney immediately without disrupting the flow of benefits to the injured worker. That reduces the number of weekly permanent disability payments made to an injured worker, and allows the attorney to receive the entire fee up front.

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WCAB Panel Holds That Email Notification Is Sufficient for QME Strike

Posted by:  Sure S. Log
Topics: LC 4062.2 striking process striking a QME QME selection process electronic strike email strike first-class mail

Labor Code § 4062.2 establishes the rules for requesting a panel of qualified medical evaluators (QMEs) when an employee is represented by an attorney. After a panel is obtained, LC 4062.2(c) states, "Within 10 days of assignment of the panel by the administrative director, each party may strike one name from the panel." The statute does not describe the appropriate method for exercising a strike, but it adds, "The administrative director may prescribe the form, the manner, or both, by which the parties shall conduct the selection process." Although the administrative director has adopted regulations related to the QME selection process in the California Code of Regulations (CCR) 29 et seq, none of the regulations discusses the striking process.

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WCAB Panels Clarify Scope of Physician-Patient Privilege

Posted by:  Sure S. Log
Topics: discovery physician-patient privilege protective order Allison medical records privacy waiver overbroad subpoena

The physician-patient privilege is not absolute in workers' compensation, but neither is a defendant's right to discovery. Although filing a claim waives the privilege for conditions placed at issue, foundational cases, such as Allison v. WCAB, 72 Cal. App. 4th 654, established that this waiver does not grant defendants unfettered access to an applicant's entire medical history. That creates a constant tension between an applicant's constitutional right to privacy and a defendant's right to relevant information.

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4th District Court of Appeal Clarifies Jurisdiction over Professional Athlete Claims

Posted by:  Sure S. Log
Topics: cumulative trauma CT jurisdiction professional athlete football exception LC 3600.5 Atlanta Falcons Gandy statutory interpretation exemption

The scope of California's jurisdiction over cumulative trauma claims filed by professional athletes has long been a contentious issue. California workers' compensation laws are generally more liberal than laws in other states. So professional athletes commonly file workers' compensation claims in California, even when they have a limited connection to the state and have long histories of playing for out-of-state teams.

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Special Report: 2nd District Court of Appeal Rejects Patterson Exception to UR/IMR

Posted by:  Sure S. Log
Topics: Utilization Review LC 4610 jurisdiction UR medical necessity Rodriguez ongoing treatment ongoing care independent medical review Patterson LC 4610.5

In an important development, the well-known Patterson case has been reversed by a Court of Appeal. Patterson is the significant panel decision that held that certain types of continuing care were not subject to utilization review (UR) and independent medical review (IMR). This decision, Illinois Midwest Insurance Agency LLC v. WCAB (Rodriguez) has held that the Patterson reasoning was inapposite of the statutory language, and has subjected continuing care to UR/IMR. BACKGROUND With the enactment of Senate Bill 863 in 2012, the California Legislature established the independent medical review (IMR) process. It became effective for all treatment requests Jan. 1, 2013. The IMR process replaced judicial review as the method to appeal UR decisions regarding all proposed medical care. Under the statutory scheme, all proposed medical care is to be requested by a physician submitting a request for authorization (RFA). That request is reviewed by UR, and may be appealed only to IMR. Judicial...

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Strict Compliance Required for Claim Numbers on QME Panel Requests

Posted by:  Sure S. Log
Topics: QME LC 4062.2 CCR 30 QME panel panel request claim number bright-line rule invalid panel

California Code of Regulations, Title 8, § 30 establishes the process by which a party may request a panel of qualified medical evaluators (QMEs) from the DWC Medical Unit. CCR 30(b) applies when an employee is represented by an attorney. It requires a party requesting a panel to provide specified information, including the claim number.

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