The opinion
Filed 11/10/25
CERTIFIED FOR PUBLICATION
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA
SECOND APPELLATE DISTRICT
DIVISION THREE
ILLINOIS MIDWEST INSURANCE B344044
AGENCY LLC,
(W.C.A.B. No. ADJ11532204)
Petitioner,
v.
WORKERS’ COMPENSATION
APPEALS BOARD and ORLANDO
RODRIGUEZ,
Respondents.
PROCEEDINGS to review a decision of the Workers’
Compensation Appeals Board. Annulled and remanded.
Bradford & Barthel and Louis A. Larres for Petitioner.
Anne Schmitz, Eric D. Ledger, and Shiloh Rasmusson for
Respondent Workers’ Compensation Appeals Board.
Tina Odjaghian Law Group, Tina B. Odjaghian and
Michelle Almary for Respondent Orlando Rodriguez.
‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗
This petition concerns the jurisdiction of the Workers’
Compensation Appeals Board (WCAB) to resolve disputes over
medical necessity determinations when a worker requires a
particular treatment for an extended period of time. Legislative
reforms to the workers’ compensation system were enacted in
2004 and 2013 to ensure that when disputes arise over whether a
requested medical treatment should be provided, medical
professionals make medical necessity determinations, rather
than the WCAB or a higher court. We conclude that there is no
exception to the statutorily mandated dispute resolution
procedures for ongoing or continual treatment. We reject
Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910
(Patterson) to the extent it set forth a contrary rule for injuries or
medical necessity determinations arising after the 2013 reforms.
When a request for authorization of treatment is submitted and
there is a dispute over whether the requested treatment is
medically necessary, that dispute must be resolved through the
utilization review and independent medical review processes,
rather than in an extra-statutory proceeding before the WCAB.
FACTUAL AND PROCEDURAL BACKGROUND
The Underlying Workers’ Compensation Claim
In November 2016, Orlando Rodriguez sustained
significant head and brain injuries while working as a mechanic
for Managed Mobile, Inc. The employer’s insurer, Procentury
Insurance Company, administered by Illinois Midwest Insurance
Agency (Illinois Midwest), admitted that Rodriguez’s injuries
were industrial, arising out of and occurring in the course of his
employment. In September 2018, Rodriguez’s primary treating
2
physician, Yong Lee, M.D., began requesting that Rodriguez
receive home health care services in six-week increments.
From September 27, 2018, through August 15, 2019,
Illinois Midwest approved at least eight different requests for
authorization of home health care. While a claims adjuster
approved some of the requests, Illinois Midwest authorized
several others only after sending them to utilization review. As
discussed in greater detail below, utilization review is a
statutorily mandated workers’ compensation procedure in which
medical professionals determine the medical necessity of a
requested medical treatment when an employer objects to the
request. (Lab. Code, § 4610, subd. (g)(2)(A).) 1
Illinois Midwest sent Dr. Lee’s September 12, 2019 request
for authorization of home health care services to utilization
review. On September 19, 2019, the utilization review physician
denied the request for authorization. The decision was mailed to
Dr. Lee, Rodriguez, and Rodriguez’s counsel on September 19,
2019. The decision was also faxed to Rodriguez’s counsel on
September 19, 2019, and to Dr. Lee on September 20, 2019.
Proceedings Before the Workers’ Compensation Judge
Rodriguez challenged the utilization review denial by
seeking an expedited hearing before a workers’ compensation
judge. On March 2, 2020, the workers’ compensation judge found
that Rodriguez was entitled to the ongoing home health care
services Dr. Lee requested. The judge concluded that because the
evidence established Rodriguez had an “ongoing and constant
need for home health care,” Illinois Midwest could not terminate
the treatment without “a showing of substantive medical
1 All further undesignated statutory references are to the
Labor Code.
3
evidence” that there was a change in Rodriguez’s condition. The
judge found Illinois Midwest had not made such a showing.
Further, the judge concluded that although the utilization review
decision was timely, it was “moot,” and since the need for home
health care was ongoing, the WCAB had jurisdiction over the
issue. The workers’ compensation judge’s ruling relied on
Patterson, a non-binding Appeals Board “significant panel”
decision. 2
Illinois Midwest filed a petition for reconsideration on
March 20, 2020. The petition requested reversal of the workers’
compensation judge’s findings that the WCAB had jurisdiction
over the dispute, that Illinois Midwest did not produce
substantive medical evidence of a change of condition, and that
Rodriguez was entitled to home health care.
The workers’ compensation judge recommended that
reconsideration be denied.
The Appeals Board’s Opinion
On January 3, 2025, the Appeals Board issued an opinion
and decision after reconsideration affirming the workers’
2 We use the term “the WCAB” to refer to the Workers’
Compensation Appeals Board generally, including the workers’
compensation judge, and “Appeals Board” to refer specifically to
the appellate judicial tribunal within the WCAB.
Only en banc decisions of the Appeals Board are binding on
future Appeals Board panels and workers’ compensation judges
“as legal precedent under the principle of stare decisis.” (Cal.
Code Regs., tit. 8 (Board Rules), § 10325, subd. (a).) “Significant
panel decisions of the Appeals Board involve an issue of general
interest to the workers’ compensation community but are not
binding precedent.” (Id., subd. (b).)
4
compensation judge’s decision. 3 Relying on Patterson, the
Appeals Board found that Rodriguez’s home health care services
were determined to be medically necessary, and that Illinois
Midwest authorized the treatment pursuant to section 4600,
subdivision (a). As a result, “any change to the established need
for medical treatment would necessarily involve a change in
applicant’s condition or circumstance, such that a renewed review
of the medical necessity of the requested treatment was
appropriate and indicated.” The Appeals Board agreed with the
workers’ compensation judge that Illinois Midwest had not
carried its burden of proof to show such a change in Rodriguez’s
condition. The decision suggested the Second District Court of
Appeal had approved of the Patterson reasoning, including the
conclusion that “where a medical treatment authorized pursuant
to section 4600(a) is determined to be medically necessary, [the
employer] is obligated to continue providing that treatment until
such time as there is a material change in circumstance. . . . [The
employer] cannot shift its burden onto [the worker] by requiring a
new [request for authorization] and starting the process over
again.”
We granted Illinois Midwest’s petition for a writ of review.
DISCUSSION
Illinois Midwest contends the Appeals Board has adopted a
position that is inconsistent with the statutory process, namely
that the WCAB has jurisdiction to decide whether ongoing
medical treatment continues to be medically necessary. The
petition therefore asserts that the Appeals Board’s award of
3 Aside from documenting a brief closure of the WCAB offices
during the COVID-19 pandemic, the record does not provide an
explanation for this almost five-year delay.
5
ongoing medical treatment was in excess of its jurisdiction and
that its reliance on Patterson violated the legislative intent of
section 4610. We agree.
I. The Statutory Scheme
A. Medical Treatment
An employer is responsible for providing an injured worker
with any medical treatment or related care that is reasonably
required to cure or relieve the effects of the injury. (§ 4600,
subd. (a).) “The right to workers’ compensation benefits is
entirely statutory.” (Stevens v. Workers’ Comp. Appeals Bd.
(2015) 241 Cal.App.4th 1074, 1087 (Stevens).) In 2004 and 2013,
legislative reforms significantly changed how workers’ requests
for treatment are considered, and the process for employers and
workers to challenge adverse decisions about the medical
necessity of specific treatments.
As the court summarized in Stevens, “Before 2004, an
employer’s obligation to cover an injured worker’s medical
treatment was largely in the hands of the worker’s treating
physician. ‘[T]here were no uniform medical treatment
guidelines in effect’ to instruct the treating physician, and there
was a rebuttable presumption that the physician’s
determinations were correct. (State Comp. Ins. Fund v. Workers’
Comp. Appeals Bd. (2008) 44 Cal.4th 230, 238 (Sandhagen).)
Back then, if an employer wanted to challenge a treating
physician’s recommendation, its only recourse was through a
‘cumbersome, lengthy, and potentially costly’ dispute resolution
process. (Ibid.) Generally, this process required the parties
either to stipulate to an agreed-upon medical evaluator or to
propose alternative medical evaluators and, if a dispute remained
after the evaluations were completed, to litigate their dispute
6
before a workers’ compensation judge. (Id. at pp. 238–239.)
Under the former process, both the worker and the employer
could challenge adverse medical-necessity determinations, and
the criteria by which those determinations were evaluated
depended on the quantity and quality of the expert evidence
presented by the parties. A party dissatisfied with the workers’
compensation judge’s decision could then appeal it to the Board,
which could assess the evidence and make factual determinations
different from those made by the judge.” (Stevens, supra, 241
Cal.App.4th at p. 1088.)
The legislative reforms that went into effect in 2004
concerned “the standards used in evaluating medical treatment
requests” and “alterations to the process for resolving the
treatment requests.” (Sandhagen, supra, 44 Cal.4th at p. 240.)
The legislative reform was “aimed at controlling skyrocketing
costs while simultaneously ensuring workers’ access to prompt,
quality, standardized medical care.” (Id. at p. 243.) With respect
to medical treatment standards, Senate Bill No. 228 (2003–2004
Reg. Sess.) (Senate Bill No. 228) added section 5307.27, “directing
the administrative director to adopt a medical treatment
utilization schedule to establish uniform guidelines for
evaluating treatment requests. (Stats. 2003, ch. 639, § 41.)”
(Sandhagen, at p. 240.)
The resulting Medical Treatment Utilization Schedule
(MTUS) incorporated evidence-based, peer-reviewed, nationally
recognized standards of care that address the frequency,
duration, intensity, and appropriateness of all treatment
procedures and modalities commonly performed in workers’
compensation cases. (§ 5307.27; Board Rules, § 9792.20 et seq.)
Senate Bill No. 899 (2003–2004 Reg. Sess.) (Senate Bill No. 899)
7
likewise amended section 4600 to define “medical treatment that
is reasonably required to cure or relieve . . . the effects of the
worker’s injury” as treatment based on the MTUS. (§ 4600,
subd. (b); Sandhagen, supra, 44 Cal.4th at p. 242.)
Senate Bill No. 899 also amended section 3202.5 to
underscore that all parties, including injured workers, must meet
the evidentiary burden of proof on all issues by a preponderance
of the evidence. (Stats. 2004, ch. 34, § 9.) “Accordingly,
notwithstanding whatever an employer does (or does not do), an
injured employee must still prove that the sought treatment is
medically reasonable and necessary. That means demonstrating
that the treatment request is consistent with the uniform
guidelines (§ 4600, subd. (b)) or, alternatively, rebutting the
application of the guidelines with a preponderance of scientific
medical evidence (§ 4604.5).” (Sandhagen, supra, 44 Cal.4th at
p. 242.)
B. Utilization Review
Before 2004, section 4062 allowed either party to object to a
physician’s medical treatment recommendation. As noted above,
any dispute was resolved through a comprehensive medical
evaluation by a medical evaluator. (§ 4062, subd. (a), eff. through
Apr. 18, 2004.) In 2004, Senate Bill No. 228 required every
employer to establish a utilization review process to streamline
the procedure for resolving medical treatment requests and to
control costs. (Stevens, supra, 241 Cal.App.4th at p. 1088.)
Under the utilization review process, a claims administrator may
approve medical treatment, but only a medical expert is
authorized to modify, delay or deny a physician’s request for
authorization of treatment. (Id. at pp. 1088–1089; § 4610.)
8
“If the treatment request is straightforward and
uncontroversial, the employer [or a claims administrator] can
quickly approve the request—utilization review is completed
without any need for additional medical review of the request. If
the request is more complicated, the employer can forward the
request to its utilization review doctor for review, since the
statute requires that the employer seek a medical opinion before
modifying, delaying, or denying an employee’s request for medical
treatment. . . . This ensures that a physician, rather than a
claims adjuster with no medical training, makes the decision to
deny, delay, or modify treatment.” (Sandhagen, supra, 44
Cal.4th at p. 241.) Utilization review of a request for treatment
must be completed and communicated within statutorily
mandated timelines. (§ 4610, subd. (i); see also Board Rules,
§ 9792.9.1, subd. (c).)
C. Dispute Resolution by Independent Medical
Review
After the utilization review process was established, an
employer could no longer use the former section 4062 procedure
to object to or deny an employee’s request for treatment unless
liability was disputed. An employer also could not contest a
utilization review determination. But the statutory scheme
continued to permit workers to use the former section 4062
process to challenge an adverse utilization review determination.
(Sandhagen, supra, 44 Cal.4th at p. 244; former § 4610,
subd. (g)(3)(A), eff. Jan. 1, 2004 to Dec. 31, 2012.) If either party
was dissatisfied with the workers’ compensation judge’s decision
in that process, that party was permitted to seek reconsideration
by the Appeals Board and further review in the Court of Appeal.
(§§ 5900, subd. (a), 5950.)
9
Effective 2013, Senate Bill No. 863 (2011–2012 Reg. Sess.)
(Senate Bill No. 863) amended the procedure for resolving
medical necessity disputes after a utilization review decision.
(Stats. 2012, ch. 363.) The Legislature expressly found that “the
current system of resolving disputes over the medical necessity of
requested treatment is costly, time consuming, and does not
uniformly result in the provision of treatment that adheres to the
highest standards of evidence-based medicine, adversely affecting
the health and safety of workers injured in the course of
employment.” (Id., § 1, subd. (d).) The Legislature also found
that “having medical professionals ultimately determine the
necessity of requested treatment furthers the social policy of this
state in reference to using evidence-based medicine to provide
injured workers with the highest quality of medical care and that
the provision of the act establishing independent medical review
are necessary to implement that policy.” (Id., § 1, subd. (e).)
The Legislature established independent medical review as
a dispute resolution process that would be “more expeditious,
more economical, and more scientifically sound than the existing
function of medical necessity determinations performed by
qualified medical evaluators appointed pursuant to Section 139.2
of the Labor Code.” (Stats. 2012, ch. 363, § 1, subd. (f).)
Under the new procedure, any dispute over a utilization
review decision regarding treatment for an injury occurring on or
after January 1, 2013, or that is communicated on or after July 1,
2013, regardless of the date of injury, must be reviewed or
appealed through the independent medical review process.
(§ 4610.5, subd. (a)(1), (2).) “A [utilization review] decision
favoring the worker becomes final, and the employer is not
permitted to challenge it.” (Stevens, supra, 241 Cal.App.4th at
10
p. 1090.) But when the utilization review decision modifies,
delays or denies a request for authorization of treatment,
independent medical review is generally the only way for the
worker to obtain review of the decision. 4 (Stevens, at p. 1090.)
Independent medical review is limited to an examination of the
medical necessity of the disputed medical treatment. (§ 4610.6,
subd. (a).) The review “is performed by an independent
organization using medical professionals to perform the review.
(§ 139.5, subd. (d)(4).) Independent medical review organizations
are under contract with the administrative director of the
Division of Workers’ Compensation. (§ 139.5, subd. (a)(1).) The
organizations must be independent of any workers’ compensation
insurer or workers’ compensation claims administrator doing
business in California. (Ibid.) The medical professionals
performing the review must be licensed physicians
knowledgeable in the treatment of the employee’s medical
condition. (§ 139.5, subd. (d)(4) & (4)(A).)” (Ramirez, supra, 10
Cal.App.5th at p. 214.)
4 There are two recognized situations in which independent
medical review may not be an exclusive remedy. First, “[i]f the
Board determines that a utilization review decision is untimely,
the Board may determine the medical necessity of the proposed
treatment based on substantial medical evidence.” (Ramirez v.
Workers’ Comp. Appeals Bd. (2017) 10 Cal.App.5th 205, 222
(Ramirez), citing Dubon v. World Restoration, Inc. (2014) 79
Cal.Comp.Cases 1298, 1312.) Second, the parties may stipulate
to resolve disputes outside of the otherwise mandated statutory
review process. (Allied Signal Aerospace v. Workers’ Comp.
Appeals Bd. (2019) 35 Cal.App.5th 1077, 1081.) Neither
circumstance is present here.
11
An independent medical review determination is deemed
the determination of the administrative director and is binding
on all parties. (§ 4610.6, subd. (g).) Any party may appeal the
independent medical review decision to the Appeals Board, but
only on limited grounds. (Id., subd. (h).) The enumerated bases
for appeal are all nonmedical issues: “(1) [t]he administrative
director acted without or in excess of the administrative director’s
powers[,] [¶] (2) [t]he determination . . . was procured by fraud[,]
[¶] (3) [t]he independent medical reviewer was subject to a
material conflict of interest that is in violation of Section 139.5[,]
[¶] (4) [t]he determination was the result of bias on the basis of
race, national origin, ethnic group identification, religion, age,
sex, sexual orientation, color, or disability[, or] [¶] (5) [t]he
determination was the result of a plainly erroneous express or
implied finding of fact, provided that the mistake of fact is a
matter of ordinary knowledge based on the information
submitted for review pursuant to Section 4610.5 and not a matter
that is subject to expert opinion.” (Ibid.)
If the Appeals Board reverses the administrative director’s
determination, the dispute is remanded for a new independent
medical review by a different organization. (§ 4610.6, subd. (i).)
Consistent with the legislative purpose of ensuring that only
medical professionals make decisions regarding the medical
necessity of treatment, section 4610.6, subdivision (i) provides:
“In no event shall a workers’ compensation administrative law
judge, the appeals board, or any higher court make a
determination of medical necessity contrary to the determination
of the independent medical review organization.”
12
Once a utilization review decision modifying or denying a
recommended treatment becomes final, either through
independent medical review or a worker’s decision not to seek
review, such a decision “shall remain effective for 12 months from
the date of the decision without further action by the employer
with regard to a further recommendation by the same physician,
or another physician within the requesting physician’s practice
group, for the same treatment unless the further
recommendation is supported by a documented change in the
facts material to the basis of the utilization review decision.”
(§ 4610, subd. (k).) Section 4610, subdivision (k) was enacted in
2013 pursuant to Senate Bill No. 863, originally as
subdivision (g)(6) (eff. Jan. 1, 2013 to Dec. 31, 2016), but remains
substantively unchanged except to exclude a utilization review
decision delaying recommended treatment (former § 4610,
subd. (g)(6), eff. Jan. 1, 2017 to Dec. 31, 2017). (§ 4610, subd. (k).)
II. Statutory Construction and Standard of Review
The parties’ dispute requires us to determine how the
above-described statutory provisions apply in the context of
ongoing treatment. “A fundamental rule of statutory
construction is that a court should ascertain the intent of the
Legislature so as to effectuate the purpose of the law.” (DuBois v.
Workers’ Comp. Appeals Bd. (1993) 5 Cal.4th 382, 387 (DuBois).)
In interpreting a statute, the text of the statutory language is
typically the best and most reliable indicator of the Legislature’s
intended purpose. (Larkin v. Workers’ Comp. Appeals Bd. (2015)
62 Cal.4th 152, 157.) “When the language is clear and there is no
uncertainty as to the legislative intent, we look no further and
simply enforce the statute according to its terms.” (DuBois, at
pp. 387–388.)
13
“ ‘[T]he Board has extensive expertise in interpreting and
applying the workers’ compensation scheme. Consequently, we
give weight to its interpretations of workers’ compensation
statutes unless they are clearly erroneous or unauthorized.’
[Citation.]” (Valdez v. Workers’ Comp. Appeals Bd. (2013) 57
Cal.4th 1231, 1239.) “Ultimately, of course, our fidelity must be
to the legislative intent as best shown by the Legislature’s use of
clear and unambiguous statutory language.” (Honeywell v.
Workers’ Comp. Appeals Bd. (2005) 35 Cal.4th 24, 34.)
III. The WCAB Did Not Have Jurisdiction To Resolve a
Dispute About the Medical Necessity of Home Health
Care Services for Rodriguez
Section 4610.5 expressly applies to any dispute over a
utilization review decision “regarding treatment for an injury
occurring on or after January 1, 2013,” or “if the decision is
communicated to the requesting physician on or after July 1,
2013, regardless of the date of injury.” (Id., subd. (a)(1), (2).) “A
dispute described in subdivision (a) shall be resolved only in
accordance with this section.” (Id., subd. (b).) “A utilization
review decision may be reviewed or appealed only by independent
medical review pursuant to this section.” (Id., subd. (e).)
The language of section 4610.5 is unambiguous and applies
to Rodriguez’s November 11, 2016 injury and the September 19,
2019 utilization review denial of Dr. Lee’s request for
authorization for home health care. Subdivision (e) irrefutably
states that independent medical review is the only means of
review or appeal of a utilization review decision. The WCAB did
not have jurisdiction to resolve a dispute over the utilization
review denial.
14
IV. The WCAB’s Application of Patterson is Inconsistent
with the Statutorily Mandated Process for Review of
Medical Necessity Determinations
Despite the language of section 4610.5, the workers’
compensation judge and the Appeals Board interpreted Patterson
as setting forth an exception to the exclusivity of utilization
review and independent medical review when an employer seeks
to deny a form of ongoing, continual treatment that the employer
has previously authorized. On this basis, both the judge and the
Appeals Board exercised jurisdiction over the parties’ dispute.
Respondents take the same position in this proceeding. We
conclude the WCAB’s reliance on Patterson was misplaced.
Patterson is distinguishable from the case at bar. Further, to the
extent Patterson announced a general exception to utilization
review and independent medical review procedures for “ongoing”
or “continual” treatment, we reject the decision’s reasoning as
inconsistent with the statutory framework.
A. The Patterson decision
In Patterson, a worker was seriously injured on the job in
1999. (Patterson, supra, 79 Cal.Comp.Cases at p. 912.) The
employer authorized nurse case manager services. (Ibid.)
Sometime later, the employer unilaterally terminated the
services. (Ibid.) In 2012, the worker challenged the decision by
seeking an expedited hearing before a workers’ compensation
judge. Initially, the employer objected to the request for a
hearing on the ground that a nurse case manager was currently
authorized to provide services, but the employee was “ ‘difficult to
deal with,’ ” resulting in frequent disputes between the worker
and the nurse case managers assigned to assist her. (Id. at
p. 913, italics omitted; see id. at p. 912.) The employer did not
15
assert that nurse case manager services were no longer medically
necessary. (Id. at p. 912.) Eventually, the parties agreed that
the worker could file another application for an expedited
hearing.
The workers’ compensation judge determined that nurse
case manager services were part of the delivery of treatment and
were necessary to the process of curing or relieving the effects of
the industrial injury. (Patterson, supra, 79 Cal.Comp.Cases at
p. 915.) The judge also ruled that the worker was not required to
secure a request for authorization from the treating physician to
be evaluated through utilization review, then independent
medical review, to obtain “ ‘the [nurse case manager] services
already found necessary by the [agreed medical evaluator].’ ”
(Ibid.) The employer sought reconsideration by the Appeals
Board.
The Appeals Board similarly concluded that the employer
could not “unilaterally cease to provide” the medical care at issue
“when there is no evidence of a change in the employee’s
circumstances or condition showing that the services are no
longer reasonably required to cure or relieve the injured worker
from the effects of the industrial injury.” (Patterson, supra, 79
Cal.Comp.Cases at p. 911.) The Appeals Board reasoned that
once the employer acknowledged the reasonableness and
necessity of nurse case manager services when it first authorized
the treatment, the worker no longer had the burden of proving
ongoing reasonableness and necessity. (Id. at p. 918.) “Rather, it
is defendant’s burden to show that the continued provision of the
services is no longer reasonably required because of a change in
applicant’s condition or circumstances. Defendant cannot shift
16
its burden onto applicant by requiring a new Request for
Authorization and starting the process over again.” (Ibid.)
In this case, the Appeals Board implicitly construed
Patterson as determining the WCAB has jurisdiction to review an
adverse medical necessity determination that involves ongoing
treatment, even when that determination is the result of
utilization review and would otherwise be subject to independent
medical review. The Appeals Board also relied on Patterson for
the proposition that when an employer authorizes some form of
treatment that will be “ongoing” or “continual,” a further request
for authorization of treatment is not necessary and, accordingly,
the employer may not make use of the utilization review process.
Neither conclusion is consistent with the relevant statutory
provisions.
B. Patterson did not involve a treatment request
that proceeded to utilization review and the
decision is therefore inapposite
With respect to the WCAB’s jurisdiction to review adverse
medical necessity determinations, Patterson concerned a scenario
that is entirely distinct from the factual history in this case. As a
result, the reasoning of the decision is neither instructive nor
persuasive.
In Patterson, the worker’s injury and the employer’s denial
of treatment occurred before independent medical review became
the exclusive path for challenging a utilization review decision in
2013. Section 4610.5 did not apply to the Patterson parties’
dispute. In addition, it is unclear whether the worker requested
nurse case manager services before the utilization review process
went into effect in 2004. But even if there was a request for
treatment after 2004, the Appeals Board described the employer’s
17
action as unilaterally terminating an authorization for treatment
that was apparently open-ended, or the termination occurred
before the authorization period expired. As a result, the WCAB
considered whether a new request for authorization was
necessary to enable the worker to challenge the termination of
the previously authorized services. There also was no dispute
that the nurse case manager services were medically reasonable
and necessary. The employer’s only reason for terminating the
services was nonmedical, specifically that the injured worker was
purportedly “ ‘difficult to deal with.’ ” (Patterson, supra, 79
Cal.Comp.Cases at p. 913, italics omitted; see id. at p. 912.) The
Appeals Board in Patterson was not confronted with the question
of whether the WCAB would have jurisdiction over an adverse
medical necessity determination, made by a medical professional,
in a statutorily mandated utilization review process.
In contrast, both Rodriguez’s injury and Illinois Midwest’s
denial of treatment occurred after 2013. Section 4610.5 squarely
applied. Further, each authorization Dr. Lee submitted
requested authorization for only six weeks of home health care
services. Thus, in September 2019, he submitted a new request
for authorization of additional home health care services. This
triggered the statutorily mandated utilization review and
independent medical review processes. The employer’s
termination of services in Patterson did not occur through the
utilization review process. To the extent Patterson implicitly
concluded that the WCAB has jurisdiction to resolve a dispute
over a medical necessity determination that has progressed
through utilization review, that holding cannot survive the
enactment of section 4610.5. The WCAB improperly relied on
Patterson as authority for the WCAB’s assertion of jurisdiction
18
over a dispute following an adverse utilization review
determination.
C. The WCAB’s interpretation of Patterson as
creating an “ongoing treatment” exception to
utilization review is inconsistent with current
law
Respondents argue that, notwithstanding Dr. Lee’s
submission of a request for authorization and sections 4610 and
4610.5, under Patterson, a request for authorization of the
ongoing home health care services was unnecessary. They
contend Illinois Midwest therefore could not use the utilization
review process to obtain an adverse medical necessity
determination, and the WCAB was not divested of jurisdiction to
resolve a dispute about the medical necessity of the requested
treatment. In answer to the petition, the Appeals Board argues
that once Illinois Midwest found the treatment “reasonable and
necessary,” it could not “place arbitrary time limits on the
authorization of treatment” and “may not unilaterally cease
provision of ongoing medical treatment and may not resubmit the
need for continuing treatment to utilization review absent a
material change in fact.”
The only direct authority the Appeals Board cites to
support its position is Patterson. Rodriguez relies on Patterson
and numerous non-binding Appeals Board decisions that have
followed Patterson’s reasoning. Yet, as described above,
Patterson is factually inapposite and considered a pre-2013 injury
and denial of treatment not subject to section 4610.5. Even
assuming Patterson was correctly decided on its own facts, the
decision cannot be extended to mean that for a post-2013 injury,
once an employer approves one request for authorization of a
19
treatment that may be required for an extended period of time,
the matter falls entirely outside of the current statutory
framework that contemplates a request for authorization,
utilization review, and independent medical review.
Under respondents’ theory, the WCAB would have
jurisdiction to determine when ongoing treatment should be
terminated even if a dispute about the propriety of such care
arises through the utilization review process after 2012.
Respondents provide no statutory authority for such an
exception, and we conclude there is none. The entire statutory
framework evinces a clear legislative purpose: to remove medical
necessity determinations from the WCAB and courts and to place
such decisions exclusively in the hands of medical professionals.
The Appeals Board’s application of Patterson directly contradicts
that legislative goal.
Respondents argue that the rationale of section 4610,
subdivision (k), should be applied to approvals of medical
treatment. They assert an approval of treatment would
accordingly remain effective for at least 12 months (as
respondent Rodriguez argues), or indefinitely (as the Appeals
Board argues), unless there is a showing of changed
circumstances. Yet, the plain language of section 4610,
subdivision (k) applies the 12-month effective date only to
utilization review decisions to deny or modify treatment
recommendations.
Respondents urge that reading “approvals” into
section 4610, subdivision (k) is necessary to prevent an employer
from repeatedly challenging treatment through utilization review
until there is a decision favorable to the employer. However,
“ ‘the judicial role in a democratic society is fundamentally to
20
interpret laws, not to write them. The latter power belongs
primarily to the people and the political branches of government
. . . .’ . . . ‘This court has no power to rewrite the statute so as to
make it conform to a presumed intention which is not expressed.’
[Citations.]” (California Teachers Assn. v. Governing Bd. of
Rialto Unified School Dist. (1997) 14 Cal.4th 627, 633.) Nothing
in section 4610, subdivision (k) indicates an intention to extend a
treatment’s approval beyond the duration requested by the
treating physician. To construe section 4610, subdivision (k) as
reflecting such an intent would conflict with both the statute’s
plain language and other provisions indicating the duration of
treatment is to be determined by a worker’s physician, consistent
with MTUS.
Indeed, as it relates to home health care assistance, the
ongoing treatment exception the Appeals Board has adopted is
inconsistent with MTUS, the guidelines which, by law, govern
medical necessity determinations. The guidelines for traumatic
brain injuries refer to the “Initial Approaches to Treatment”
guideline, which expressly address home health care services.
The guidelines recommend that as to frequency, dose, or duration
of home health care services: “Frequency is individualized by the
provider’s assessment and evaluation of the patient’s healthcare
needs and is detailed in a treatment plan. The authorization
should include estimated services, hours, and duration of services
on a daily/weekly basis. Reassessment of the medical necessity of
the home health care services should be performed at regular
intervals.” 5 (Initial Approaches to Treatment, supra, at p. 17.)
5 Initial Approaches to Treatment, American College of
Occupational and Environmental Medicine (ACOEM) October 22,
2021, page 17 [adopted and incorporated into the MTUS
21
This guideline illustrates that the duration and ongoing
necessity of home health care services is a medical issue, falling
within the scope of what the Legislature has deemed should be
determined by medical professionals, not the WCAB or higher
courts. The guideline also illustrates that while home health care
services may be ongoing, the MTUS anticipates regular
reassessments of medical necessity. This stands in contrast to
the Appeals Board’s position that medical necessity is
presumptively established unless and until the employer
demonstrates a change in circumstances, and that reassessments
otherwise fall outside of the statutory framework for medical
necessity determinations.
Moreover, the Appeals Board’s “ongoing” or “continuing”
care exception would open the door to a large number of cases
involving medical necessity determinations proceeding on an
alternative, non-statutory dispute resolution path, defeating the
Legislature’s express goal of eliminating the “cumbersome,
pursuant to Board Rules, § 9792.22, subd. (a)(3)] (American
College of Occupational and Environmental Medicine, Initial
Approaches to Treatment (Oct. 22, 2021) (Initial Approaches to
Treatment)
<https://www.dir.ca.gov/dwc/DWCPropRegs/2021/MTUS-
Evidence-Based-Update-December2021/Initial-Approaches-to-
Treatment.pdf> [as of Nov. 6, 2025], archived at
<https://perma.cc/8M3V-JDQZ>); Traumatic Brain Injury,
ACOEM November 15, 2017, page 225 [adopted and incorporated
into the MTUS pursuant to Board Rules, § 9792.24.5] (American
College of Occupational and Environmental Medicine, Traumatic
Brain Injury (Nov. 15, 2017)
<https://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Evidence-
Based-Updates/Final-Regulations/Traumatic-Brain-Injury.pdf>
[as of Nov. 6, 2025], archived at <https://perma.cc/L5CD-9H4G>).
22
lengthy, and potentially costly process” that existed before the
2004 and 2013 legislative reforms. (Sandhagen, supra, 44
Cal.4th at p. 238.) Because there is no statutory authority for the
exception the Appeals Board has adopted, there is no definition of
what types of care or medical treatments fall into the category of
“care of an ongoing nature.” In fact, in the reconsideration
decision in this case, the Appeals Board concluded, without
qualification, that where a “medical treatment authorized
pursuant to section 4600(a) is determined to be medically
necessary, defendant is obligated to continue providing that
treatment until such time as there is a material change in
circumstance.” Taken at face value, this conclusion would mean
that for any treatment once authorized, a dispute over a future
medical necessity determination would have to be resolved by the
WCAB, rather than by medical professionals through the
utilization review and independent medical review procedures.
Had the Legislature envisioned such a significant exception to
the otherwise mandatory dispute resolution processes, we expect
it would have made that clear in the comprehensive amendments
to the law.
A review of the express language of the statutes reveals the
opposite. No statutory provision indicates that an employer may
only object to a requested treatment the first time it is requested.
No provision indicates that once a treatment is authorized, no
further request for authorization is necessary unless the
employer establishes a change in circumstances. No provision
sets forth the burden shifting framework the WCAB has
described for “ongoing” or “continual” treatments, even when
additional requests for authorization are submitted. Further, no
provision states or suggests that any one-time authorization of a
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medical treatment is necessarily deemed to be of indefinite
duration. Indeed, the converse is true; the duration of treatment
is to be determined, authorized, and reviewed consistent with the
MTUS, and the employee continues to bear the burden of proving
that the medical treatment is reasonable and necessary.
The Appeals Board also erred in construing this court’s
summary denials of other petitions as approval of Patterson. The
Appeals Board described this court’s summary denial of a petition
for review in National Cement Co. v. Workers’ Comp. Appeals Bd.
(Rivota) (2021) 86 Cal.Comp.Cases 595, as a decision that
“upheld the Appeals Board’s application of Patterson to award an
applicant continued inpatient care.” Similarly, the Appeals
Board’s decision discussed Los Angeles County MTA v. Workers’
Comp. Appeals Bd. (Burton) (2024) 89 Cal.Comp.Cases 977,
noting that this court denied a petition for a writ of review.
A summary denial of a petition for judicial review of an
Appeals Board ruling decides no issues and has no precedential
value. (Ralphs Grocery Co. v. Workers’ Comp. Appeals Bd. (1995)
38 Cal.App.4th 820, 827, fn. 7; Coltherd v. Workers’ Comp.
Appeals Bd. (1990) 225 Cal.App.3d 455, 462.) The Appeals Board
incorrectly characterized a case summary of Rivota as the
decision of this appellate court “upholding” the Appeals Board’s
application of Patterson. No appellate court has adopted the
Appeals Board’s reasoning in Patterson, and we decline to do so
here.
We acknowledge the Appeals Board’s concern regarding
arbitrary time limits on the authorization of treatment. We note
the case manager testimony in this case that requests for
authorization “go out every six weeks which is required so that
the home health care people can get paid.” However, the MTUS
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guidelines regarding home health care services call for regular
reassessments. The worker’s treating physician is tasked with
determining the appropriate duration for any medical treatment
and the amount of time that should pass before the physician will
reevaluate whether the treatment should continue. The MTUS
guidelines contemplate that the duration of treatment will be
included in the treatment plan, and, theoretically, a physician
would request authorization for treatment consistent with that
plan.
Even if the employer’s or insurer’s control of the payment
process has influenced the system—an issue we do not decide and
on which we express no opinion—the statutory framework does
not permit the abandonment of the mandatory utilization review
and independent medical review procedures as a response. There
is no statutory authority for a two-prong system in which only
initial requests for treatment are subject to utilization review and
independent medical review, while future requests for the same
treatment are exempt, allowing non-medical professionals at the
WCAB or a higher court to make medical necessity
determinations. 6
6 Our opinion is limited to the factual scenario presented
here: the treating physician requested authorization for
treatment of a specific duration, and the request was timely
submitted and addressed in utilization review. We do not
consider or decide whether a different analysis may apply when,
for example, an employer authorizes treatment, then
subsequently terminates the treatment without using the
utilization review process, or when the parties stipulate to the
terms of treatment and agree to forgo utilization review and
independent medical review procedures.
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The statutory language is explicit and unambiguous, and
this court must enforce the statute according to its terms.
(DuBois, supra, 5 Cal.4th at pp. 387–388.) Irrespective of the
reasons why a treating physician selects a particular duration of
treatment in a request for authorization, the request is subject to
utilization review if the employer objects, and to independent
medical review after that. Nothing in the statute prohibits an
employer from seeking utilization review of subsequent requests
for more of the same medical treatment. This conclusion is in
harmony with the statutory framework as a whole, including the
2004 enactment of the utilization review process. The intent of
the Legislature is evident in the statutory framework. That
intent was to have medical professionals decide medical issues
while streamlining the process and reducing the cost for medical
treatment by using MTUS and other medical evidence and
standards. The duration of treatment, and the necessity of
ongoing treatment, are medical issues. Applying the reasoning of
Patterson to any ongoing medical treatment could ultimately
expand it to all treatment under the guise of approval at some
previous point in time. Such a result would frustrate the purpose
of the utilization review and independent medical review
processes.
The WCAB did not have jurisdiction to review the
utilization review determination denying Rodriguez home health
care. Rodriguez’s remedy was to file a request for review through
independent medical review, which he did not do.
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DISPOSITION
The decision of the Appeals Board after reconsideration is
annulled. The matter is remanded to the Appeals Board for
further proceedings consistent with this opinion.
CERTIFIED FOR PUBLICATION
ADAMS, J.
We concur:
EDMON, P. J.
EGERTON, J.
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