Workers’ Compensation · Primary-source case analysis
Stevens: IMR Was Constitutional, but the WCAB Retained Limited Statutory Review
Decision: Stevens v. WCAB, No. A143043 (Cal. Ct. App. Oct. 28, 2015).
Stevens separates the medical-necessity determination assigned to independent medical review (IMR) from the Workers’ Compensation Appeals Board’s limited authority to review a decision made without statutory authority. It upheld the review system but preserved a legal question about the denial of home-health care.
Treatment requests after permanent total disability
Frances Stevens developed complex regional pain syndrome after a work injury and was found permanently totally disabled. Her physician requested medications and a home health aide. Utilization review denied the requests, and IMR affirmed.
The constitutional challenges failed
The court held that the Legislature’s plenary authority over workers’ compensation permitted the IMR structure. The process did not violate separation of powers, the constitutional requirement of substantial justice and review, or federal due process because the worker could submit evidence and receive reasoned administrative review.
Medical necessity and legal authority differ
The WCAB generally cannot reweigh the anonymous physician’s medical-necessity determination. But it may review whether the determination was adopted without authority. Here, the reviewer’s categorical statement about personal care required examination of the Medical Treatment Utilization Schedule (MTUS). If the schedule permitted the requested care and no other reason supported denial, that legal error could permit the Board to set the determination aside. Stevens, slip opinion, pages 25–26.
Disposition
The court remanded for the Board to decide whether the home-health denial was unauthorized. The result did not convert the Board into a second medical reviewer; it preserved review of the decision’s statutory boundary.
Key takeaways
- Distinguish medical disagreement from legal-authority error.
- IMR remains the forum for medical-necessity disputes.
- Section 4610.6(h) lists limited grounds for WCAB review; it does not authorize a fresh choice between medical opinions.
- Preserve the treatment request, UR rationale, IMR record, and asserted review ground.
Review your IMR determination and WCAB appeal options
Mishra X Trial Lawyers can review California independent medical review denials to determine whether the decision exceeded statutory authority. Bring your primary treating physician’s Request for Authorization (RFA), Utilization Review denial, IMR final determination, and medical reports. Call (949) 343-9735 or email office@mishrax.com.