Illinois Midwest v. WCAB: Is Ongoing Care Exempt From Utilization Review?

Illinois Midwest Insurance Agency LLC v. Workers’ Compensation Appeals Board, 115 Cal.App.5th 1168 (2025), addresses whether an insurer may send a new request for previously authorized ongoing treatment through utilization review.

The Court of Appeal said yes on these facts, but the California Supreme Court has granted review.

Read the published opinion on CourtListener.

A Dispute Over Continuing Home Health Care

Orlando Rodriguez suffered significant head and brain injuries while working as a mechanic in November 2016. The employer’s insurer accepted the injuries. Beginning in September 2018, his physician repeatedly requested home health care in six-week increments. Illinois Midwest approved at least eight requests, some after utilization review.

A New Request Was Denied

In September 2019, the physician submitted another six-week request. A utilization-review physician denied it on medical-necessity grounds. Rodriguez sought an expedited WCJ hearing rather than obtaining relief through independent medical review.

The WCJ and Board Applied Patterson

The judge found an ongoing and constant need for care. Relying on the significant-panel decision in Patterson v. The Oaks Farm, the judge held that the administrator could not stop care without substantive medical evidence of changed circumstances and treated the UR decision as moot. The Appeals Board affirmed in January 2025.

The Court Rejected an Ongoing-Treatment Exception

The Second District held that the post-2013 statutes contain no general exception for ongoing treatment. Each request sought only six weeks of care, so the September 2019 submission was a new request. Once a timely UR decision denied treatment on medical-necessity grounds, the statutory challenge was IMR, not adjudication of medical necessity by the WCAB.

Why Patterson Was Different

Patterson involved pre-2013 law, apparently open-ended nurse case-management services, and termination for a nonmedical reason without a UR medical-necessity decision. The court held that it could not be expanded to remove later, finite requests from the modern UR/IMR framework.

What the Court Left Open

The court did not decide whether a different analysis applies when an employer terminates authorized treatment without using UR or when parties stipulate to treatment and agree to forgo UR and IMR.

Practical Lessons

A worker receiving a UR denial should immediately evaluate its timeliness and validity and preserve the deadline to request IMR. Keep every request, approval, denial, proof of service, and treatment record. Whether an authorization was finite or genuinely open-ended may be crucial.

Supreme Court Review Is Pending

The Supreme Court will decide whether an exception exists for previously authorized ongoing treatment and whether the WCAB may hear an appeal from an adverse UR decision in that setting. Until then, Illinois Midwest is not settled California law.