Defendant denied electrician's request for more time at rehabilitation centre after he suffered traumatic brain injury
Terminating medical treatment – previously authorized to relieve an injured worker from an industrial injury’s effects – would breach section 4600(a) of California’s Labor Code unless supported by substantial medical evidence, a recent ruling said.
The applicant in the case of Perez-Lopez vs. Power by Spark; State Compensation Insurance Fund was working as an electrician when he sustained industrial injuries to his head, knees, upper back, lower back, and his left hand’s fingers.
The applicant’s primary treating physician diagnosed him with significant issues due to his traumatic brain injury. He found cognitive deficits, orthopedic problems, crippling anxiety, and an inability to safely perform daily living activities. He determined that the applicant required participation in Casa Colina Transitional Living Center’s residential program.
The applicant’s request for authorization (RFA) asked for four weeks of inpatient physical rehabilitation at Casa Colina. The defendant conducted a utilization review, which certified the requested inpatient treatment. In October 2020, the applicant was admitted to the residential program.
In December 2020, the applicant’s RFA asked for inpatient care from January to February 2021. The defendant’s reviewer denied the request upon finding no evidence of clinically meaningful improvement after the initial inpatient program. In February 2021, the defendant’s reviewer denied another request for inpatient care.
In April 2021, the workers’ compensation administrative law judge ruled in the applicant’s favor. The judge found that the defendant should not unilaterally deny inpatient care services at Casa Colina unless there was a change in circumstance that would justify issuing a new determination at a utilization review. The judge cited the case of Patterson v. The Oaks Farm (2014) and later decisions.
The defendant filed a petition for reconsideration, which the workers’ compensation judge dismissed. A panel of the Workers’ Compensation Appeals Board of California agreed with the judge’s decision.
Section 4600(a) of the Labor Code provided that an industrially injured worker was entitled to medical treatment reasonably required to cure or to relieve the injury’s effects. The treatment would be at the employer’s expense.
Here, the judge correctly determined that the principles in the case of Patterson were applicable such that the defendant should continue authorizing residential care at Casa Colina until there was a change in the applicant’s circumstances that would warrant a new utilization review determination, the panel said.
There was no evidence of any change in the applicant's condition or circumstances that would support initiating a utilization review to reevaluate his inpatient treatment, the panel added.