Your doctor recommended surgery, an MRI, or physical therapy and the insurance company said “no,” you aren’t alone. At Lee Partners Law: Injury Attorneys, we see these denials every week.
In California, the insurance company doesn’t just get to ignore your doctor, they use a bureaucratic process called Utilization Review (UR) and Independent Medical Review (IMR) to control costs. If you don’t fight back correctly, you could lose your treatment and your case value.
Step 1: The Request for Authorization (RFA)
The process begins when your treating physician submits a Request for Authorization (RFA). Whether it’s for surgery, injections, or diagnostic testing, this is the formal trigger for the insurance company to respond.
Step 2: Utilization Review (UR) – The First “No”
Instead of a doctor who has examined you, the insurance company sends your RFA to a Utilization Review (UR) physician. This doctor reviews your file behind a desk and decides if the care meets “medical necessity” guidelines (MTUS).
The critical factor most workers miss: UR is governed by strict legal deadlines under Labor Code § 4610.
- Decisions must be made within 5 -14 days of the initial request .
Step 3: When the Insurance Company Breaks the Rules
At Lee Partners Law, we look for “defective” UR decisions. If the insurance company misses a deadline or fails to serve the decision properly under 8 CCR § 9792.9.5, the denial may be invalid.
When UR is defective, the Workers’ Compensation Appeals Board (WCAB) regains jurisdiction. This allows a judge, not an insurance-paid doctor, to decide if your treatment is necessary. This is a massive legal lever that we use to get our clients the care they deserve.
Step 4: Independent Medical Review (IMR) Deadlines
If the UR denial is timely and valid, your only recourse is Independent Medical Review (IMR).
- The Clock is Ticking: You generally have only 30 days to request IMR from a denial of care.
- The Trap: If you miss this deadline, the denial becomes final for one year.
- Over 90% of denied treatment requests are upheld by Utilization Review.
Why Contact Lee Partners Law: Work Injury Attorneys?
Navigating the UR/IMR maze requires more than just a lawyer; it requires a specialist. David A. Lee and Michael Lee are Certified Specialists Attorneys in Workers’ Compensation Law. This designation by the State Bar of California is held by a small percentage of attorneys and signifies deep expertise in handling complex medical disputes.
We don’t just “file forms.” We:
- Identify and challenge defective UR decisions.
- Force the insurance company to follow the Labor Code.
- Ensure your medical recovery translates into maximum case settlement value.
Don’t let a paper denial end your recovery. If your treatment has been denied or delayed, contact Lee Partners Law: Work Injury Attorneys today for a consultation.
