CompFox AI Summary
This case involves an applicant who sustained a back and neck injury, seeking authorization for lumbar surgery. The defendant's utilization review (UR) denials for the surgery were found to be procedurally defective and, in one instance, untimely. The Appeals Board denied the defendant's petition for reconsideration. The Board found that due to the untimeliness of the June 9, 2014 UR denial, jurisdiction lay with the Board to determine medical necessity. Based on substantial medical evidence supporting the surgery, the Board upheld the original award of treatment.
Full Decision Text1 Pages
This case involves an applicant who sustained a back and neck injury, seeking authorization for lumbar surgery. The defendant's utilization review (UR) denials for the surgery were found to be procedurally defective and, in one instance, untimely. The Appeals Board denied the defendant's petition for reconsideration. The Board found that due to the untimeliness of the June 9, 2014 UR denial, jurisdiction lay with the Board to determine medical necessity. Based on substantial medical evidence supporting the surgery, the Board upheld the original award of treatment.
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