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Chapter 4.5. Division of Workers' Compensation
Subchapter 2. Workers' Compensation Appeals Board--Rules and Practice Procedure
Article 5. Pleadings and Forms
Article 20. Review of Administrative Orders

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§10957.1. Petition Appealing Independent Medical Review Determination of the Administrative Director.

(a) This section shall apply only to petitions appealing an independent medical review (IMR) determination of the Administrative Director (AD) regarding treatment for: (1) an injury occurring on or after January 1, 2013; and (2) an injury occurring on or before December 31, 2012, if the decision is communicated to the requesting physician on or after July 1, 2013. This section shall not apply where the injured employee asserts that a defendant's utilization review is untimely or otherwise invalid unless, as an alternative challenge, the employee is also appealing the IMR determination.

(b) An aggrieved party may file a petition appealing the AD's independent medical review (IMR) determination. For purposes of this section, a “determination” includes a decision regarding medical necessity and a decision that a dispute is not subject to independent medical review.

(c) The petition shall be filed with the Workers' Compensation Appeals Board no later than 20 days after service of the IBR determination. An untimely petition may be summarily dismissed.

(d) The caption of the petition shall identify it as a “Petition Appealing Administrative Director's Independent Medical Review Determination.”

(e) The caption of the petition shall include: (1) the injured employee's first and last names; (2) the name(s) of the defendant(s) involved in the IMR dispute; (3) the case number assigned by the AD to the IMR determination; and (4) the adjudication case number, if any, assigned by the Workers' Compensation Appeals Board to any related application for adjudication of claim(s) previously filed.

(f) The petition shall include a copy of the IMR determination and proof of service to that determination.

(g) The petition shall comply with each of the following provisions:

(1) The petition shall be limited to raising one or more of the five grounds specified in Labor Code section 4610.6(h).

(2) The petition shall set forth specifically and in full detail the factual and/or legal grounds upon which the petitioner considers the IMR determination to be unjust or unlawful, and every issue to be considered by the Workers' Compensation Appeals Board. The petitioner shall be deemed to have finally waived all objections, irregularities, and illegalities concerning the IMR determination other than those set forth in the petition.

(3) The petition shall comply with the requirements of sections 10842(a) & (c), 10846, and 10852. It shall also comply with the provisions of section 10845, including but not limited to the 25-page restriction.

(4) Any failure to comply with the provisions of this subdivision shall constitute valid ground for summarily dismissing or denying the petition.

(h) A copy of the petition shall be concurrently served on: (1) the adverse party(ies) or provider(s) or, if represented, their attorney or non-attorney representatives; (2) the injured employee or, if represented, the employee's attorney; and (3) the Division of Workers' Compensation, Independent Medical Review Unit (IMR Unit).

(i) Upon receiving notice of the petition, the IMR Unit may download the record of the independent bill review organization into EAMS, in whole or in part. The Workers' Compensation Appeals Board, in its discretion, may: (1) admit all or any part of the downloaded IMR record into evidence; and/or (2) permit the parties to offer in evidence documents that are duplicates of ones already existing in the downloaded IMR record.

(j)(1) The petition shall not be placed on calendar unless a declaration of readiness is filed. The declaration of readiness may be either concurrently filed with the petition or subsequently filed. Any declaration of readiness shall be concurrently served on the adverse party(ies) or provider(s) and on the IMR Unit.

(2) Notwithstanding the filing of a declaration of readiness, a petition appealing an IMR determination shall be deferred if at the time of the determination the defendant is also disputing liability for the treatment for any reason besides medical necessity.

(k) The petition shall be adjudicated by a workers' compensation judge at the trial level of the Workers' Compensation Appeals Board utilizing the same procedures applicable to claims for ordinary benefits, including but not limited to the setting of a mandatory settlement conference unless an expedited hearing is being conducted in accordance with Labor Code section 5502(b). However, the IMR determination shall be presumed correct and shall be set aside only upon proof by clear and convincing evidence of one or more of the Labor Code section 4610.6(h) statutory grounds for appeal.

(l) Any party aggrieved by a final decision, order, or award of the workers' compensation judge may file a petition for reconsideration with the Appeals Board within the same time and in the same manner specified for petitions for reconsideration. The workers' compensation judge shall prepare a report on the petition for reconsideration in accordance with section 10860, unless the judge acts on a timely filed petition for reconsideration in accordance with section 10859.

(m) If the IMR determination is reversed by the workers' compensation judge or the Appeals Board, the dispute shall be remanded to the AD in accordance with Labor Code section 4610.6(i).

Note: Authority: Sections 133, 5307, 5309 and 5708, Labor Code. Reference: Sections 4610.6, 5500, 5501, 5502, 5700 et seq., 5800 et seq. and 5900 et seq., Labor Code; and Sections 10250, 10409, 10507, 10508, 10842, 10845, 10846, 10852, 10856, 10859 and 10860, California Code of Regulations, title 8.

HISTORY

1. New section filed 9-23-2013; operative 10-23-2013. Submitted as a file and print by the Workers' Compensation Appeals Board pursuant to Government Code section 11351 (Register 2013, No. 39).

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