The Letter That Says No
Your doctor examined you, decided you need an MRI, or physical therapy, or a surgical consult, and submitted a request. Weeks later a letter arrives from a company you’ve never heard of, signed by a physician you’ve never met, in a state you may not live in, explaining that the treatment your doctor ordered is not medically necessary.
That letter is a utilization review decision, and it is one of the most demoralizing documents in the California workers’ compensation system. It is also appealable — on a clock that starts running the moment it’s served on you.
What Utilization Review Actually Is
Under Labor Code section 4610, every claims administrator must maintain a utilization review program to decide whether requested treatment is medically necessary. When your treating physician submits a Request for Authorization, it goes into that program. A reviewing physician compares the request against California’s Medical Treatment Utilization Schedule — the MTUS, the state’s evidence-based treatment guidelines — and issues one of four outcomes: approve, modify, delay, or deny.
Two features of this system explain most of the frustration it generates.
First, the reviewer never examines you. The decision is made on paper, from the records submitted. A reviewer in another state, working from an incomplete file, is making a call about a body they have not seen.
Second, the guidelines are presumptively correct. The MTUS is treated as the standard, and treatment outside it requires the requesting physician to show why the guidelines don’t fit your case. A well-supported request that explains why your situation is an exception fares far better than a bare request — which is one reason the quality of your treating doctor’s paperwork matters as much as their clinical judgment.
The Deadlines — Both Theirs and Yours
This system runs on deadlines, and they cut in both directions.
What the claims administrator owes you
- Prospective or concurrent review: a decision within five normal business days of receiving the request for authorization and the supporting information — and in no event more than 14 days from your physician’s treatment recommendation.
- Retrospective review (treatment already provided): within 30 days of receiving the information reasonably necessary to decide.
- Expedited review is available where the ordinary timeframe would seriously jeopardize your life or health, or subject you to severe pain that can’t be adequately managed while you wait.
What you owe, and it’s short
If the decision denies, modifies, or delays your treatment, your route of appeal is Independent Medical Review. The application must be submitted:
- Within 30 days after the utilization review decision is served on you, for most medical treatment disputes.
- Within 10 days for pharmacy formulary disputes.
Thirty days is not very long, and it does not pause because you were in pain, or waiting to hear back from your doctor’s office, or trying to understand what the letter meant. The IMR application form typically arrives attached to the denial itself — which means the envelope that delivers the bad news also contains the remedy, and a lot of people never realize it.
How Independent Medical Review Works
IMR moves the medical-necessity question to a reviewer outside the claims administrator’s own program. The reviewer’s identity is not disclosed. The review is done on the records. There is no hearing, no testimony, and no opportunity to explain yourself in person.
The determination is binding, and the grounds for challenging it are narrow — essentially fraud, conflict of interest, bias, or a plainly erroneous finding of fact, rather than simple disagreement with the medical conclusion.
Since the record is all there is, what goes into the file is the whole ballgame. A complete submission — imaging, the treating physician’s reasoning, documentation of the conservative care you already tried and how it failed, and a clear explanation of why the MTUS guideline doesn’t fit your presentation — is a materially different proposition from a bare form with a few pages attached. This is the single highest-leverage point in the entire appeal, and it is the one most often handled thinly.
The Question Worth Asking First: Was the Denial Even Timely?
Here is the part that gets overlooked, and it can change everything.
Medical necessity disputes belong to IMR, not to a judge. But whether the utilization review process was conducted properly and on time is a separate question — and that one a workers’ compensation judge can reach.
A utilization review decision that misses its statutory deadline may be invalid. When that happens, the medical-necessity question can come back before a judge rather than being locked into the IMR track. That is a meaningfully better forum for an injured worker, because a judge can weigh your treating physician’s opinion in a way the IMR process does not.
So the first thing to check on any denial is the arithmetic: when was the request for authorization submitted, when was the decision made, and when was it served? Those dates are on the paperwork, and they are frequently wrong. Reviewing them is not an exotic legal maneuver — it’s arithmetic — but it requires knowing that the deadlines exist.
What to Do When a Denial Arrives
- Write down the date you received it. Keep the envelope. Your 30 days runs from service.
- Find the IMR application. It is usually attached to the denial. Don’t discard the packet.
- Check the dates. Compare the request for authorization date against the decision date against the service date.
- Call your treating physician’s office. Ask what was submitted with the request. Incomplete submissions cause a large share of denials, and a supplemental report addressing the MTUS directly can be decisive.
- Don’t stop treating. Gaps in care get used against you later, both on the medical question and on the credibility of your symptoms.
- Get advice before the 30 days runs. Not on day 29.
Frequently Asked Questions
What is utilization review?
It’s the process the claims administrator uses to decide whether your doctor’s requested treatment is medically necessary, measured against California’s Medical Treatment Utilization Schedule.
How long do I have to appeal a UR denial?
Generally 30 days from service of the decision for medical treatment disputes, and 10 days for pharmacy formulary disputes.
Can a judge overrule a UR denial?
Not on medical necessity — that goes to IMR. But a judge can address whether the utilization review was timely and procedurally proper, and an untimely denial may be invalid.
Do I have to keep paying for treatment that was denied?
You should not be paying out of pocket for treatment of an accepted work injury. If you’re being billed, that’s a problem to raise immediately rather than absorb.
What if IMR upholds the denial?
IMR determinations are binding with narrow grounds for challenge. In some cases a changed condition or new medical evidence can support a fresh request for authorization, which starts the process again on the new facts.
Don’t Let the 30 Days Run
The most common way an injured worker loses a treatment fight in California is not by losing the argument. It’s by missing the window to make it.
Kim LaValley and Kyle Adamson have decades of experience with medical treatment denials in California workers’ compensation cases across Nevada County, Placer County, and the Sacramento region. If you’re holding a denial letter, call 530-362-7188 before the clock runs out — there’s no charge for the conversation.
You can also read more about how we handle California workers’ compensation claims.
This article is general information about California workers’ compensation law and is not legal advice. Appeal deadlines are strict and run from the date a decision is served. For advice about your specific denial, speak with a workers’ compensation attorney promptly. Authoritative source material: Labor Code § 4610; Labor Code § 4610.5; California Division of Workers’ Compensation.
