Discover how this ruling changes HR’s role in handling long-term workers’ comp care for employees in California
California’s top court just ruled that only medical experts – not the WCAB – can decide ongoing workers’ comp care disputes after a review denial.
On November 10, 2025, the California Court of Appeal, Second Appellate District, Division Three, issued its decision in Illinois Midwest Insurance Agency LLC v. Workers’ Compensation Appeals Board and Orlando Rodriguez. The ruling clarifies that when a utilization review physician denies ongoing treatment for a workplace injury, the only way to challenge that denial is through independent medical review – not through the Workers’ Compensation Appeals Board (WCAB).
The case began after Orlando Rodriguez, a mechanic for Managed Mobile, Inc., suffered significant head and brain injuries in November 2016. The employer’s insurer, Procentury Insurance Company, administered by Illinois Midwest Insurance Agency, admitted the injuries were industrial and work-related. Starting in September 2018, Rodriguez’s primary treating physician, Dr. Yong Lee, requested home health care services in six-week increments.
Illinois Midwest approved several of these requests, sometimes after sending them to utilization review – a process in which medical professionals determine the medical necessity of requested treatment. In September 2019, Dr. Lee’s request for continued home health care was denied by a utilization review physician. Rodriguez challenged the denial by seeking an expedited hearing before a workers’ compensation judge.
The judge found Rodriguez was entitled to ongoing home health care and concluded Illinois Midwest could not terminate the treatment without showing substantive medical evidence of a change in Rodriguez’s condition. The judge’s decision relied on Patterson v. The Oaks Farm, a non-binding Appeals Board decision that allowed the WCAB to intervene in ongoing care disputes.
Illinois Midwest filed for reconsideration, arguing that the WCAB did not have jurisdiction to resolve disputes over ongoing medical treatment after a utilization review denial. The Appeals Board affirmed the judge’s decision, again relying on Patterson.
The appellate court reviewed the legislative reforms from 2004 and 2013, which were enacted to ensure that medical necessity determinations are made by medical professionals through utilization review and independent medical review, not by the WCAB or courts. The court held that there is no exception for ongoing or continual treatment. If a request for authorization is denied through utilization review, the only way to challenge that denial is through independent medical review. The court rejected the reasoning in Patterson to the extent it conflicted with the statutory framework.
The appellate court annulled the Appeals Board’s decision and remanded the matter for further proceedings consistent with its opinion. The court did not discuss insurance policy clauses, as the dispute focused on statutory procedures rather than policy interpretation.
This decision means that ongoing medical treatment disputes in California workers’ compensation cases must be resolved through the statutory medical review process. The WCAB cannot decide medical necessity once a utilization review determination has been made. The ruling underscores the importance of following statutory procedures and coordinating with claims administrators to ensure compliance with California’s workers’ compensation laws. This case sets a clear standard for how ongoing treatment disputes should be handled in the state.
