Wiltz: Old Pharmacy Bills Required a Date-Specific Review and Medical Explanation

An award for future medical care can leave a worker and a pharmacy facing a difficult question years later: Why is the claims administrator still disputing medication prescribed for the accepted injury? In Wiltz v. City of Los Angeles, the answer required separate examination of the treatment requests, the review procedure available at the time and the medical explanation for the drugs. The Workers’ Compensation Appeals Board set aside a pharmacy’s $50,871.51 lien award and returned those questions for further proceedings.

Future medical care remained open, but the pharmacy’s charges were disputed

Gloria Wiltz injured her right knee while working as a receiving clerk for the City of Los Angeles in December 1994. A May 1997 award provided for future medical care. The Prescription Center Pharmacy later sought payment for compounded medication and lidocaine patches supplied between September 2011 and January 2014 on prescriptions from Dr. Metcalf.

The September 2021 lien trial proceeded on documents, without witness testimony. The judge awarded the pharmacy $50,871.51, a 10 percent statutory increase and interest. His explanation relied on the treating physician’s verified reports and on his conclusion that the City’s utilization review—the process for assessing treatment recommendations—was late. A second lien, submitted by Siena Management Group, was left out of the decision. These facts and the competing positions appear in Wiltz.

The service year changed the review question

The City disputed the judge’s timing analysis. It argued, among other things, that the initial services were subject to retrospective review and that some requests lacked the required authorization paperwork. The panel required a closer examination rather than resolving every disputed review date itself.

The judge’s report had relied on a pharmaceutical-review provision that took effect in January 2017. The bills at issue ended in 2014. That later provision could not supply the answer for those services. As Wiltz explains, the analysis first required identifying a valid request for authorization and then the applicable kind of review: Prospective review before treatment, concurrent review during an inpatient stay, or retrospective review after previously unapproved services. The panel directed the judge to examine the validity and timeliness of review for each claimed service date under the applicable rules.

Continuing prescriptions and previously authorized care were different facts

The judge also relied on Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910, 918. That decision concerned an employer’s attempt to stop care it had already authorized as reasonably required, without substantial medical evidence of changed circumstances.

The pharmacy’s file lacked competent evidence that the City had previously authorized these medications on an ongoing basis or that a valid initial utilization review had found them medically necessary. The Wiltz panel therefore found the premise for applying Patterson missing. The important distinction was the evidence of prior authorization, rather than the fact that prescriptions continued over time.

Authority to hear the dispute did not answer the medical question

The panel separated the services before January 1, 2013 from the later services in this file. It explained the earlier medical-evaluation dispute process and the later independent medical review system. For the later services, whether utilization review had been valid and timely mattered to which decision-maker could resolve medical necessity. The opinion discusses Willette v. Au Electric Corp. (2004) 69 Cal.Comp.Cases 1298, 1308 and Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298, 1305, 1309–1312 in explaining that distinction.

A separate burden remained when the WCAB could decide medical necessity. A lien claimant seeking payment had to prove the necessary elements of its lien, including that the treatment was reasonably required. The panel applied Kaiser Foundation Hospitals v. Workers’ Comp. Appeals Bd. (Martin) (1985) 39 Cal.3d 57, 67 and explained that the claimant stood in the injured worker’s shoes. Wiltz connects the review procedure to that continuing evidentiary burden.

The medical explanation had to engage with the treatment guidelines

The Medical Treatment Utilization Schedule, or MTUS, supplies presumptively correct treatment guidelines. The panel required an explanation of how the prescribed treatment fit the relevant guidelines, or the applicable evidence supporting treatment outside them. A passing statement that treatment was “per MTUS” would not do that work.

The City’s review reports had raised specific concerns: Whether first-line treatment had been tried, whether lidocaine produced significant functional improvement and whether the stated indication supported these patches. Those were the reviewers’ concerns, not new clinical findings made by the panel. The judge needed to address the medical-necessity evidence. A prescription alone did not show that the guideline requirements were met or successfully rebutted. Wiltz explains why the original award lacked that analysis.

What the January 27 decision required next

The panel rescinded the October 2021 order and returned the matter to the trial level. The judge had to decide the omitted Siena Management lien and examine the pharmacy’s authorization requests, the applicable review procedure, individual review dates and medical support. The disposition was a return for further proceedings, rather than a final determination that the pharmacy would recover or lose its charges.

For someone reviewing an old treatment dispute, the useful work is concrete: Identify the service date and actual request, locate the corresponding response and earlier authorization evidence, then connect the physician’s explanation to the medical issue disputed. Our analysis of Dubon addresses the review-timing distinction more broadly. The separate guide to older medication bills focuses on organizing those different questions without applying today’s rules indiscriminately to past care.