Two Ways to Appeal a Denial of Treatment
If you have an accepted workers' compensation case in the State of California, you are probably familiar with the feeling of having your treatment denied. When this occurs, don't sit back and let it happen! Here are two ways to fight back.
1. File an IMR ApplicationAlong with every denial of treatment (even a partial denial or "modified" treatment), there comes a three-page form called an "Application for Independent Medical Review," also known more casually as an "IMR Appeal." You can find a blank version here for reference: https://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMRForm_Application.pdf. You have to be sure to follow the instructions and send all three pages to the proper address within 30 days of the initial denial of treatment. You also must be sure to sign in two places: at the bottom of Page 1 and in the middle of Page 3. Without these signatures, IMR will not review your application, and the denial of your treatment will remain valid for 12 full months.
2. File a DOR for an Expedited HearingTo be very clear, this remedy is only available to you if the denial of treatment was untimely. To put it as simply as possible, the defendant has 5 business days to make a decision about whether to approve or deny the requested treatment. Then there is an additional day allowed for the decision to be sent to the parties. If the decision is not rendered within this period of time, then it is untimely, and this means that you can have a judge review the treatment to decide upon whether it is reasonably medically necessary.
File a DOR (Declaration of Readiness) for an Expedited Hearing on the issue, which you can find here: https://www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/ADJ/DWCCAForm10208_3.pdf. Check "Entitlement to medical treatment per Labor Code § 4600, except issues determined pursuant to Labor Code §§ 4610 and 4610.5" as the reason for the hearing.
It is very important to understand that you need to have your ducks in a row if you go this route. This requires you to have the following evidence: (1) the denial of the treatment, (2) the original request for treatment, and (3) documentation from the requesting doctor that describes in detail the reasons that the requested treatment is "reasonably medically necessary" (assuming that the doctor probably did not include this information on the request form).
Can You Do Both?Yes! If the denial of treatment was not provided in a timely fashion, then don't skip Step 1 thinking that you can only do Step 2! Do both at the same time! This is a jurisdictional issue, which is a technical concept. Essentially, IMR is the only entity with jurisdiction to decide whether a denial of treatment is proper... UNLESS the decision is not timely, in which case the jurisdiction shifts to the judge. You only have 30 days to pursue the IMR route, and you're not sure which way the judge will go, so you're fine to pursue both angles at the same time.