Chapter 4.5. Division of Workers' Compensation
Subchapter 2. Workers' Compensation Appeals Board--Rules and Practice Procedure
Article 8. Petitions Related to Administrative Orders

§ 10575. Petition Appealing Independent Medical Review Determination.

(a) An aggrieved party may file a petition appealing the Administrative Director's independent medical review (IMR) determination. For purposes of this rule, a “determination” includes a decision regarding medical necessity and/or a decision that a dispute is not eligible for independent medical review.

(b) 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 incorrect, 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. Any petition that fails to comply with any of the following requirements may be subject to summary dismissal.

(c) The petition shall be filed in accordance with rule 10615 no later than 30 days after service of the IMR determination.

(d) The petition and any additional documents or pleadings related to the petition shall be served on the IMR Unit in accordance with rule 10632.

(e) The petition shall be captioned “Petition Appealing Administrative Director's Independent Medical Review Determination” and shall include the assigned ADJ number and the IMR case number assigned by the Administrative Director.

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

(g) Upon receiving notice of the petition, the IMR Unit may download the record of the independent medical 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.

(h)(1) The petition shall not be placed on calendar unless a Declaration of Readiness to Proceed is filed.

(2) Notwithstanding the filing of a Declaration of Readiness to Proceed, 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.

(i) If the IMR determination is rescinded by the workers' compensation judge or the Appeals Board, the medical treatment dispute shall be returned to the Administrative Director with an order specifying the basis for the rescission and an order to submit the dispute to IMR in accordance with Labor Code section 4610.6(i).

Note: Authority cited: 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.

HISTORY

1. Renumbering of former section 10957.1 to section 10575, including amendment of section heading, section and Note, filed 12-17-2019; operative 1-1-2020. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 2019, No. 51).