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.
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...
As stated in Labor Code § 4610(a), utilization review is the process a defendant uses to "prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, ..." (emphasis added). UR is the process to determine only whether a request for treatment is medically necessary. It does not determine other issues.
Labor Code 4610(i)(1) normally requires a utilization review (UR) determination to be made within "five normal business days from the receipt of a request for authorization for medical treatment and supporting information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician." But LC 4610(i)(3) requires an expedited review when the employee faces an "imminent and serious threat to his or her health, ... or the normal timeframe for the decision-making process ... would be detrimental to the employee’s life or health or could jeopardize the employee’s ability to regain maximum function." In those situations, the UR decision must be made in a timely fashion "not to exceed 72 hours after receipt of the information reasonably necessary to make the determination."
