Giron v. KDF Forestry: Peer-Review Calls Did Not Establish a UR Deadline Extension

Case Analysis: Giron v. KDF Forestry

In Ramiro Giron v. KDF Forestry; Everest National Insurance Company, administered by Sedgwick CMS, Decision After Reconsideration, April 6, 2026, No. ADJ15322493, the Workers’ Compensation Appeals Board (WCAB) held that claims administrators cannot extend the mandatory five-normal-business-day utilization review (UR) timeline merely by attempting peer-review phone calls. Reversing a trial judge’s decision, the Appeals Board clarified that under operative Labor Code section 4610(j)(2), extending the UR deadline up to fourteen days requires immediate written notification to both the treating physician and the injured worker specifying the missing medical information required to make a determination.

Factual Background and Record Evidence

The applicant, Ramiro Giron, sustained an industrial low back injury while employed as a tree trimmer for KDF Forestry. Nearly two years prior to the dispute, the applicant had undergone an L3-S1 micro decompression performed by Christian Athanassious, M.D. Following a subsequent incident involving acute back pain radiating down his left leg while lifting branches, Dr. Athanassious issued a Request for Authorization (RFA) on September 4, 2025, seeking L5/S1 anterior and posterior spinal fusion with instrumentation, bone grafts, intraoperative X-rays, and an anterior co-surgeon.

The RFA and thirty-nine pages of supporting treating records were successfully faxed and received by Sedgwick CMS on September 4, 2025 at 11:10 AM, as confirmed by fax transmission records and acknowledged in Sedgwick’s subsequent determination. Sedgwick referred the RFA to a UR reviewer on September 10, 2025. The peer review report indicated that the reviewer made phone calls to Dr. Athanassious’s office on September 10 leaving messages with staff, left a voicemail message on September 11, and left a message containing a denial determination on voicemail on September 12, 2025.

On September 12, 2025, Sedgwick issued an unsigned adverse determination denying the requested spinal fusion surgery as not medically necessary. The denial document did not include a verified proof of service conforming to board regulations.

Giron, slip op. at 3–4.

Procedural Posture and Trial Level Order

The matter proceeded to trial on October 6, 2025 on two primary issues: whether Sedgwick’s UR determination dated September 12, 2025 was timely based on claimed peer-to-peer review extensions, and whether the requested lumbar fusion surgery constituted reasonable medical treatment. The applicant testified through an interpreter that he was comfortable proceeding with the surgery if authorized.

On January 2, 2026, the workers’ compensation administrative law judge (WCJ) issued Findings and Order determining that by timely attempting telephonic contact with Dr. Athanassious on September 10 and 11, the defendant validly extended the UR timeline from five days to fourteen days. The WCJ concluded that the UR decision was timely, thereby divesting the WCAB of jurisdiction to address medical necessity. In the accompanying report, the WCJ acknowledged the lack of a proof of service but stated the court was willing to assume the denial was timely conveyed. The applicant sought reconsideration of that ruling.

Giron, slip op. at 1–3.

Statutory Reconsideration Clock Under Amended Section 5909

Before addressing the UR dispute, the Appeals Board evaluated its jurisdiction under Labor Code section 5909, as amended effective July 2, 2024. Under section 5909(a), a petition for reconsideration is deemed denied by operation of law unless acted upon within sixty days from the date the trial judge transmits the case to the Appeals Board. Transmission is established in EAMS by the event entry indicating the case was sent to the Recon board.

The EAMS record confirmed the case was transmitted to the Appeals Board on February 5, 2026, making Monday, April 6, 2026 the sixtieth day. The WCJ served the report on February 5, 2026, providing actual notice of transmission to the parties pursuant to section 5909(b)(2). Because the board issued its decision on April 6, 2026, it timely acted within the statutory window.

Giron, slip op. at 6–7.

Why the Earlier Telephone-Extension Approach Did Not Resolve This Request

On the substantive UR issue, the Appeals Board analyzed the statutory interplay governing review timelines. Labor Code section 4610(i)(1) dictates that prospective UR decisions must be made within five normal business days from receipt of the RFA and necessary supporting information. Because Sedgwick received the RFA on September 4, 2025, UR action was required on or before September 11, 2025, unless legally extended.

The WCJ relied on a 2015 panel decision addressing a former statutory provision. Giron explained that the provision had been repealed effective January 1, 2018, so that earlier telephone-extension reasoning was no longer persuasive for this 2025 request. The panel applied the operative written-notification requirement instead. Giron, slip op. at 6–7.

Under operative Labor Code section 4610(j)(2), an extension beyond five business days is permissible only when the employer lacks information reasonably necessary to make a determination. In such cases, the employer must immediately notify the physician and employee in writing that a decision cannot be made within five days and specify the exact information required. The existing record did not establish the written-notification basis for an extension. Telephone attempts alone did not supply that missing proof, and the WCJ had to address the factual issue on remand.

Furthermore, the Board addressed the WCJ’s assumption regarding service. Under Bodam v. San Bernardino County, a UR decision made on time but not timely communicated is legally untimely. WCAB Rule 10625(c) requires a dated, verified declaration of service, and Evidence Code section 641’s presumption of receipt applies only upon proof of proper mailing. The WCJ erred by assuming timely conveyance without evidentiary support.

Giron, slip op. at 8–9.

Limitations and Record Consequences

The Appeals Board granted reconsideration, rescinded the WCJ’s Findings and Order, and remanded the matter for further trial-level proceedings. The Board instructed the WCJ to determine whether written notification under section 4610(j)(2) was ever sent, create a proper record regarding service and receipt, and identify the specific date of injury required under Labor Code section 3208.1.

The disposition returned the case for further proceedings; it did not grant medical treatment. The Board did not make a final finding that UR was untimely or authorize the spinal surgery. Instead, it established that insurers cannot satisfy section 4610(j)(2) through telephone logs alone, reinforcing the necessity of strict compliance with written extension rules. For a practical guide on auditing claims administrator extension notices, see our analysis on workers' comp UR extension notices and peer-review calls.