CompFox AI Summary
The Workers' Compensation Appeals Board granted reconsideration, affirming the finding that the defendant's utilization review (UR) decision denying knee surgery was defective due to missing documentation. However, the Board rescinded the administrative law judge's order to return the request to UR. Instead, the Board awarded the requested knee surgery and related treatment, finding substantial medical evidence in the record supported its medical necessity. This decision was based on subsequent case law that allows the Board to decide medical necessity when UR is defective.
Full Decision Text1 Pages
The Workers' Compensation Appeals Board granted reconsideration, affirming the finding that the defendant's utilization review (UR) decision denying knee surgery was defective due to missing documentation. However, the Board rescinded the administrative law judge's order to return the request to UR. Instead, the Board awarded the requested knee surgery and related treatment, finding substantial medical evidence in the record supported its medical necessity. This decision was based on subsequent case law that allows the Board to decide medical necessity when UR is defective.
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