5 things to consider when appealing a Utilization Review denial

In California, injured workers’ compensation claims undergo a specific evaluation process known as Utilization Review (UR). In this crucial step, a doctor reviews the medical care provided and uses the state’s evidence-based guidelines, or the Medical Treatment Utilization Schedule (MTUS), to make an assessment.

If the doctor approves your request for a certain treatment, you can proceed with getting the necessary medical care. However, if the doctor denies your request, it doesn’t mean it’s the end of the road. Fortunately, you have the right to appeal the decision.

Factors of a successful UR appeal

Before embarking on the appeals process, it’s important to consider several key factors that could enhance your chances of success:

1. Timeliness: The clock starts ticking once you receive an Independent Medical Review (IMR) notice. You only have 30 days to appeal a UR decision, so swift action is vital.
2. Medical evidence: Gather all relevant medical evidence and documents supporting the necessary treatment you requested. This could include medical records, test results and supporting letters from your physician.
3. Compliance with Medical Treatment Utilization Schedule (MTUS): Your doctor must provide a strong reason for the recommended treatment to align with the MTUS standards.
4. Legal counsel: You should consider consulting a lawyer specializing in California’s workers’ compensation law. They could provide invaluable guidance and possibly enhance your chances of a successful appeal.
5. Persistence: Don’t let a denial discourage you. A UR denial doesn’t equate to not getting the treatment you need. There’s still hope if you navigate the appeal process effectively and assert your rights.

The appeal process can be complex. However, it’s essential to maintain thoroughness for speed because you only have one chance at this appeal. If this appeal is denied, the treatment in question cannot push through. So, it’s critical to prepare and proceed cautiously with your appeal.

Taking careful yet swift action is key

Organizing evidence to validate your need for a specific medical treatment is crucial. Remember, as an injured worker, you have rights. Among these is the right to appeal a denial with precision. As such, to approach this process with your best interests in mind, an attorney may be able to help you through the process and ensure the protection of your rights.