Zuniga v. Workers' Comp. Appeals Bd.

228 Cal. Rptr. 3d 294, 19 Cal. App. 5th 981
CourtCalifornia Court of Appeal, 5th District
DecidedJanuary 12, 2018
DocketA143290
StatusPublished
Cited by1 cases

This text of 228 Cal. Rptr. 3d 294 (Zuniga v. Workers' Comp. Appeals Bd.) is published on Counsel Stack Legal Research, covering California Court of Appeal, 5th District primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Zuniga v. Workers' Comp. Appeals Bd., 228 Cal. Rptr. 3d 294, 19 Cal. App. 5th 981 (Cal. Ct. App. 2018).

Opinion

Miller, P.J.

*984As a result of amendments to California's workers' compensation law that took effect in 2013, an injured worker may challenge a decision denying medical treatment by requesting a determination of medical necessity from an independent medical review (IMR) organization. ( Lab. Code, §§ 139.5, 4610.5.1 ) The IMR organization, which is regulated by the Division of Workers' Compensation of the Department of Industrial Relations (Division) and operates under contract with the administrative director of the Division, designates one or more medical professionals to review pertinent medical records, determine whether the disputed treatment is medically necessary, and prepare a written report including statutorily-required findings to support the reviewer's determination. ( § 139.5, subd. (a)(1), § 4610.6, subds. (a) through (e) ; Cal. Code Regs., tit. 8, § 9792.10.1 et seq. ) The determination of the IMR organization is deemed to be the determination of the administrative director, and is binding on all parties, subject *298to appeal on narrow statutory grounds. ( § 4610.6, subds. (g) & (h).)

Of significance to the matter before us, the IMR organization is required by statute to describe the qualifications of the medical professionals who prepare the determination of medical necessity and to keep the names of the reviewers confidential in all communications outside the IMR organization. ( § 4610.6, subd. (f).)

Petitioner Saul Zuniga availed himself of the IMR process and then petitioned the Workers' Compensation Appeals Board (Board) to disclose the names of the reviewers. When the Board declined to do so, citing section 4610.6, subdivision (f), Zuniga filed this writ petition contending that the statute does not prohibit the Board from ordering disclosure and that any contrary reading violates due process. We granted Zuniga's petition for writ of review and now affirm the Board.

FACTUAL AND PROCEDURAL BACKGROUND

A. Background on Worker's Compensation

To provide context, we summarize the relevant aspects of workers' compensation procedure as it exists in the wake of major reforms that took effect in 2004 and 2013, drawing on the account by our colleagues in Division One in Stevens v. Workers' Comp. Appeals Bd. (2015) 241 Cal.App.4th 1074, 1081, 194 Cal.Rptr.3d 469 ( Stevens ).)

An injured worker's physician "submits a treatment recommendation that is reviewed under the employer's UR [utilization review] process. (§ 4610.) A *985'medical director' designated by the employer or insurer reviews all information 'reasonably necessary' to determine whether to approve, modify, or deny the recommendation. (§ 4610, subd. (d).) ... [¶] A UR decision favoring the worker becomes final, and the employer is not permitted to challenge it. (See § 4610.5, subd. (f)(1).) But if the UR decision modifies, delays, or denies a request, the worker may seek review through an IMR. ( § 4610.5, subd. (d).) In other words, the IMR process gives workers, but not employers, a second chance to obtain a decision in their favor." ( Stevens , supra , 241 Cal.App.4th at p. 1090, 194 Cal.Rptr.3d 469, fn. omitted.)

"The IMR is performed by an independent review organization, which assigns medical professionals to review pertinent medical records, provider reports, and other information submitted to the organization or requested from the parties. ( § 4610.6, subd. (b).) The physician reviewer must approve the requested treatment if it is 'medically necessary based on the specific medical needs of the employee and the standards of medical necessity as defined in subdivision (c) of Section 4610.5.' ( § 4610.6, subd. (c).) The IMR determination must state whether the disputed service is medically necessary, identify the employee's medical condition and the relevant medical records, and set forth the relevant findings associated with the standards of medical necessity. ( § 4610.6, subd. (e).) These standards include, in the order listed in the statute: (1) the [Medical Treatment Utilization Schedule, which was adopted in 2007 and since updated], (2) peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed treatment; (3) nationally recognized professional standards; (4) expert opinion; and (5) generally accepted standards of medical practice. ( § 4610.5, subd. (c)(2).) If multiple medical professionals review a case, a majority must agree on the final decision, and if they are evenly split, the decision must favor the worker. ( § 4610.6, subd. (e).) Decisions must include the reviewing medical professionals' qualifications, but the independent review *299organization is to 'keep the names of the reviewers confidential in all [outside] communications.' ( § 4610.6, subd. (f).) The IMR determination is deemed as a matter of law to constitute the determination of the director [the administrative director of the Division] and is binding on all parties. ( § 4610.6, subd. (g).)

"A worker who disputes the IMR determination may appeal it to the Board. ( § 4610.6, subd. (h).) ... [T]he only specified grounds for relief ... are that the director acted without authority, the decision was procured by fraud, the physician reviewer had a material conflict of interest, the decision was the result of bias, or the decision was based on a plainly erroneous fact that is not a matter subject to expert opinion. ( § 4610.6, subd. (h).) [2 ] If the Board *986reverses the decision ... it may only remand the case for a new IMR. ( § 4610.6, subd. (i).)"3 ( Stevens , supra , 241 Cal.App.4th at pp. 1090-1091, 194 Cal.Rptr.3d 469.) The new IMR is to be performed by a different independent review organization, but if a different organization is not available, as will be the case if there is only one authorized IMR organization, the new IMR is to be performed by a different reviewer in the organization that performed the previous IMR. ( § 4610.6, subd. (i).)

"Finally, a Board decision can ... be challenged by filing a writ of review in the Court of Appeal. (§ 5950.) ... [A]ppellate courts are ... explicitly precluded from making 'a determination of medical necessity contrary to the determination of the independent medical review[er]' ( § 4610.6, subd. (i) ) ...." ( Stevens , supra , 241 Cal.App.4th at p. 1091, 194 Cal.Rptr.3d 469.)

B. Reviews of Zuniga's Treatment Plan

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Bluebook (online)
228 Cal. Rptr. 3d 294, 19 Cal. App. 5th 981, Counsel Stack Legal Research, https://law.counselstack.com/opinion/zuniga-v-workers-comp-appeals-bd-calctapp5d-2018.