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Sandhagen and lack of written authorization (California)

PostPosted: Tue May 05, 2009 11:51 am
by laesquire
SCENARIO:

1. Knee surgery requested, authorized in writing. UR Dr. does surgery.


2. Therapy post knee surgery requested . UR no response. Adjuster is fine with therapy. MPN Doctor does NOT do therapy due to lack of writtten authorization by the adjuster.

QUESTION:
1. If no UR denial, does the adjuster have to actually authorize the treatment in writing ?

It seems under Sandhagen, no UR denial on accepted injury body part treatment is authorized by operation of law.

Re: Sandhagen and lack of written authorization (California) (Ca

PostPosted: Tue May 05, 2009 3:59 pm
by rider001
Wow Ur doc does surgery? That seems like a conlict of interest. Was he in the MPN?

Re: Sandhagen and lack of written authorization (California)

PostPosted: Wed May 06, 2009 5:01 pm
by steelmanlaw
can a doc be on the MPN and UR at the same time? wouldn't there have to be a congenital abnormality (of the doc, not the IW) for that to be the case.

but seriously, as to the real issue, even before Sandhagen, the code and regs gave employer strict timeline within which to delay, submit, accept or reject a treatment authorization request. Sandhagen just relied on the UR structure to say that defendant does not have the option of going AME/QME instead of UR. Sandhagen also appears to some to imply that thereafter neither party can do the 4062 dance on extent and scope, though the concurring opinion in Sandhagen says that parties can still go by way of 4062: AME/QME, but only after compliance with 9792.9/10 time frames. (see especially section 9792.10(a)(1).) thus, failure of UR to timely respond is in a sense authorization by operation of law, all other things being equal.

Re: Sandhagen and lack of written authorization (California)

PostPosted: Mon May 11, 2009 6:43 am
by jakelast@aol.com
Sandhagan only stands for the proposition that UR is a required process for an employer to authorize, delay, deny or modify medical treatment and UR reports that are not timely obtained are not admissable.

There is no "authorization by operation of law" and medical treatment must still meet the definition of treatment under lc 4600, which means it must be consistent with the MTUS. The problem the defendant has is there is no evidence it has to present on the issue. However the PTP must still be able to demonstrate the treatment is consistent with the MTUS in the event of a dispute.

With all that, it is difficult to imagine PT after a surgery would not be consistent with the MTUS. In my experience it is also unusual that a claims adm doesn't not respond to a request for authorization at all. If the adjuster is OK with the PT some companies will allow the adjuster to authorized, some still require UR. I suspect the request for the TX may not have been properly communicated to trigger the use of UR. A request for authorization needs to be in either a PR-2 or a narrative report marked "request for authorization" at the top of the first page. (It can also be a doctor's first). If the adjuster is aware of the request, the adjuter should be the one to forward the request to UR and follow up on the approval.