| History:
(a) If either the employee or employer objects to a medical determination made by the treating physician concerning any medical issues not covered by Section 4060 or 4061 and not subject to Section 4610, the objecting party shall notify the other party in writing of the objection within 20 days of receipt of the report if the employee is represented by an attorney or within 30 days of receipt of the report if the employee is not represented by an attorney. Employer objections to the treating physician's recommendation for spinal surgery shall be subject to subdivision (b), and after denial of the physician's recommendation, in accordance with Section 4610. If the employee objects to a decision made pursuant to Section 4610 to modify, delay, or deny a treatment recommendation, the employee shall notify the employer of the objection in writing within 20 days of receipt of that decision. These time limits may be extended for good cause or by mutual agreement. If the employee is represented by an attorney, a medical evaluation to determine the disputed medical issue shall be obtained as provided in Section 4062.2, and no other medical evaluation shall be obtained. If the employee is not represented by an attorney, the employer shall immediately provide the employee with a form prescribed by the medical director with which to request assignment of a panel of three qualified medical evaluators, the evaluation shall be obtained as provided in Section 4062.1, and no other medical evaluation shall be obtained.
(b) The employer may object to a report of the treating physician recommending that spinal surgery be performed within 10 days of the receipt of the report. If the employee is represented by an attorney, the parties shall seek agreement with the other party on a California licensed board-certified or board-eligible orthopedic surgeon or neurosurgeon to prepare a second opinion report resolving the disputed surgical recommendation. If no agreement is reached within 10 days, or if the employee is not represented by an attorney, an orthopedic surgeon or neurosurgeon shall be randomly selected by the administrative director to prepare a second opinion report resolving the disputed surgical recommendation. Examinations shall be scheduled on an expedited basis. The second opinion report shall be served on the parties within 45 days of receipt of the treating physician's report. If the second opinion report recommends surgery, the employer shall authorize the surgery. If the second opinion report does not recommend surgery, the employer shall file a declaration of readiness to proceed. The employer shall not be liable for medical treatment costs for the disputed surgical procedure, whether through a lien filed with the appeals board or as a self-procured medical expense, or for periods of temporary disability resulting from the surgery, if the disputed surgical procedure is performed prior to the completion of the second opinion process required by this subdivision.
(c) The second opinion physician shall not have any material professional, familial, or financial affiliation, as determined by the administrative director, with any of the following:
(1) The employer, his or her workers' compensation insurer, third-party claims administrator, or other entity contracted to provide utilization review services pursuant to Section 4610.
(2) Any officer, director, or employee of the employer's health care provider, workers' compensation insurer, or third-party claims administrator.
(3) A physician, the physician's medical group, or the independent practice association involved in the health care service in dispute.
(4) The facility or institution at which either the proposed health care service, or the alternative service, if any, recommended by the employer's health care provider, workers' compensation insurer, or third-party claims administrator, would be provided.
(5) The development or manufacture of the principal drug, device, procedure, or other therapy proposed by the employee or his or her treating physician whose treatment is under review, or the alternative therapy, if any, recommended by the employer or other entity.
(6) The employee or the employee's immediate family.
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Relevant Case Law
Note: When applicant P&S, must comply with 4061/4062 before obtaining new treating physician.
Note: New, uncontested med. evidence rebutted presumption that treating physician's findings were correct; Earlier treating physician's opinion no less relevant than QME's.
Note: Sufficiency of evidence necessary to rebut treating dr. presumption; award reduction required per 4065.
Note: Lien claimant denied due process when applicant fails to notify of medical objection; should be cured by amending pleadings.
Note: Proper procedure for supplementing medical record at trial.
Note: Definition of rights, duties, penalties for pre-application discovery.
Note: Utilization Review medical reports are not sufficient evidence for benefits determinations.
Note: Utilization review is not a condition precedent to a defendant's use of a QME/AME under section 4062(a).
Note: The Legislature intended to require employers to conduct utilization review when considering requests for medical treatment, and not to permit employers to use section 4062 to dispute employees' treatment requests. The language of section 4610 and 4062 mandates this result.
Note: Medical evaluation and reporting procedures of former section 4062 remain operative in represented cases with injury date before 1/1/05.
Note: [Unpublished] Utilization review process is mandatory and SCIF cannot resort to proceedings under 4062 as a method for disputing injured worker's treatment request.
Note: Five part procedural test on utilization review objections; UR reports were admissible because they are specifically required in the statutory scheme under LC 4610 and are therefore relevant on issues involving medical care, disapproving their prior holding in Czarnecki.
Note: QME may be PTP after compliance with 4061, 4062, but disputes must be resolved per Reg 9785 before presumption apply.
Note: Where statutory process has been followed for spinal surgery second opinion, and the delay is due solely to the DWC's failure to comply with its obligation under section 4062(b), there is no reasonable basis for terminating the second opinion process.
Note: [En Banc] The procedures and timelines governing objections to a treating physician's recommendation for spinal surgery are contained in Labor Code sections 4610 and 4062*fn2 and in Administrative Director (AD) Rules 9788.1, 9788.11, and 9792.6(o).
Note: Former section 4060 et seq. remains operative for represented cases with a date of injury before January 1, 2005.
Note: A defendant may satisfy its obligation under Labor Code section 4600 to provide reasonable medical treatment by transferring an injured worker into an MPN in conformity with applicable statutes and regulations regardless of the date of injury or the date of an award of future medical treatment.
Note: The WCAB acted within its authority in prohibiting the use of a report generated by an untimely utilization review process in subsequent proceedings challenging the treatment decision.
Note: An employee has 'received' a comprehensive medical-legal evaluation when the employee attends and participates in the medical evaluator's examination.
Note: It is contrary to the spirit of section 4062 to permit a retrospective determination of a permanent and stationary date when to do so would be to allow a belated objection to a medical determination by the treating physician.
Note: UR deadlines are mandatory - failure to meet deadline precludes use of UR procedure for med treatment dispute in question.
Note: LC 4062 as it existed prior to SB 899 applies to represented employees injured before 1/1/05.
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