Lisa Simmons En Banc- denied body parts? (California)

[laesquire]

SCENARIO:

1. Accepted Right Shoulder injury.

2. Denied internal medicine and psychiatric.

3. Defense requests a Panel QME Internal Medicine and Psychiatric. The judge denies it and says per Lisa Simmons vs State of CA Dep Mental Health En Banc that UR must first review the request for treatment. So the request for an order in Psychiatric and Internal Medicine denied.

QUESTION:
1. Does the defense have to go through UR on DENIED body parts?

[laesquire]

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[jpod]

I know the DWC Audit says even if the body part is denied the request for Rx is still subject to UR.

I will let others comment on the en banc.

[jonbrissman]

Seems like someone has confused apples and oranges. Whether or not UR has to review a request for medical treatment is off-point. The request for a panel QME is a request for a medical-legal evaluation, not a request for treatment. UR has no standing (of which I am aware) to review a medical-legal referral. How is a Rx involved? And how did a WCJ get involved in approving or denying a medical-legal referral?

JCB

[jpod]

Jon I think I can answer why the defendant is asking a Judge to order a med-legal panel. If the body parts in question have been denied the Med Unit will not issue a panel to a defendant wihtout an order from a WCJ.

I am only specualting however.

[jonbrissman]

Jpod, thanks. That answers one of my questions.

JCB

[jakelast@aol.com]

The WCJ may be thinking that any issue involving Medical treatment needs to be addressed by UR in order to determine if it is medically indicated. The issue of whether the medical treatment is related to the original injury can be addressed by UR but that report may not be admissable on the actual nature and extent of injury issue.

In Simmons the issue was whether the UR docs comments on the relationship of a body part was admissable on the issue of nature and extent of injury with defendant arguing it was and applicant arguing only a lc 4062(a) report was admissable on that issue.. The WCAB held the report is not admissable on that issue but could be the necessary trigger to allow defendant to object to the opinion of the PTP regarding that relationship and seek a medical legal report on the issue.

However the decision does not require UR to address that issue, it merely allows the issue to be triggered by UR. A LC 4062(a) objection as to the nature and extent of injury is also a basis for moving forward. If the Medical Unit has already issued a panel, it will not issue another one absent agreement or an order of the WCAB.

[vampireinthenight]

A rep from the medical unit told me that they WILL issue a panel when causation is at issue. It is not properly before a UR physician. You just have to tell the medical unit that it is a "Simmons issue" and they will issue it.