CompFox AI Summary
The Appeals Board reconsidered a WCJ's decision upholding utilization review (UR) denials for an MRI and EMG. While other contentions regarding the UR physician's qualifications and licensing were dismissed based on precedent, the Board found the UR decisions invalid due to untimely communication. Specifically, the defendant failed to prove by substantial evidence that the UR decisions were communicated by phone, fax, or email within 24 hours of being made. The matter is returned to the trial level to determine medical necessity, as the UR denials are void.
Full Decision Text1 Pages
The Appeals Board reconsidered a WCJ's decision upholding utilization review (UR) denials for an MRI and EMG. While other contentions regarding the UR physician's qualifications and licensing were dismissed based on precedent, the Board found the UR decisions invalid due to untimely communication. Specifically, the defendant failed to prove by substantial evidence that the UR decisions were communicated by phone, fax, or email within 24 hours of being made. The matter is returned to the trial level to determine medical necessity, as the UR denials are void.
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