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Workman Comp Utilization Review and QME

Sacramento, CA |

If the QME requested services doesn't the Utilization Review have to honor it?

Attorney Answers 3


  1. If the QME requires diagnostic tests to give medical-legal opnions, this does not go to UR. If QME recommends current treatment, it has no legal effect. As of 7/1/13, "Under SB 863, future medical treatment disputes would no longer be subject to resolution by AMEs or QMEs. Starting January 1, 2013, and phasing in completely for all dates of injury after July 1, 2013, if a medical treatment dispute results in the delay, denial or modification of treatment recommended by the injured worker’s treating physician, the only method of resolution available to employee after utilization review would be an Independent Medical Review (IMR) conducted pursuant to the procedures set forth in Labor Code §4610.5." See http://www.wcwebzine.com/a-z/qualifiedmedicalevaluator.htm


  2. The only thing that triggers the insurance company's obligation to consider authorizing a treatment request, is a request for authorization from your treating doctor, not from a QME. If there was a utilization review denial prior to July 1 2013 that was submitted to your QME, what the QME says will probably control. If the denial was on or after 7/1/13, what your QME says is largely irrelevant.


  3. Utilization review and independent medical review are for TREATMENT requests only. If the QME is requesting services in order to better form his opinion, that is not treatment and does NOT go to UR or IMR.

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