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TWO RECENT DECISIONS PROVIDE GOOD NEWS FOR THE DEFENSE, REGARDING THE INDEPENDENT MEDICAL REVIEW (IMR) PROCESS:

 

1. AN UNTIMELY IMR DECISION DOES NOT NULLIFY THE IMR DECISION ON MEDICAL NECESSITY:


In a published decision, the 2nd Appellate Court, in the
decision of SCIF v. Dorothy Margaris, reversed the prior
Panel decision in which the Appeals Board had determined the late issuance of the
IMR decision to uphold Utilization Review's non-certification of medical treatment
was improper, as IMR shall issue its decision within the 30 Day timeline as per labor
Code section 46710(d).


The Appellate Court indicated in Margaris that the statutory language using the
term "shall" was ambiguous. Therefore, the Court looked past such language in
reaching their decision noting the word "shall" in the context of this particular
statute was directory versus mandatory.
COMMENTS: The prior Panel decision left the Defense with being punished for
something not within its control; a late IMR report.
This Published Appellate Court decision equitably finds a late IMR report will not
negate the IMR decision, as the Legislative intent on statutes regarding the IMR
process are intended to defer treatment issues to the IMR doctor, as opposed to a
Workers Compensation Judge, who does not have a medical degree and should not
be making such decisions.


The Court also points to the fact there is no penalty nor consequence for
noncompliance indicated in the statute itself. The lack of such a provision in the
statute, the Court found, was indicative of the legislature's the time frame of 30 days
to issue an IMR decision is to be obligatory permissive, as opposed to mandatory.
Therefore, even if an IMR decision is not issued within 30 days of submission to
Maximus, the IMR doctor's findings and conclusions are not negated, and are
conclusive, regarding the medical necessity for treatment.


2. IMR DOCTOR NOT LICENSED TO PRACTICE MEDICINE IN CALIFORNIA
DOES NOT NULLIFY THE IMR DECISION:
In a recent Noteworthy Panel Decision, the Appeals Board, in Navroth v. Mervyn's
Store, determined a Utilization Review Independent Medical Review (IMR) doctor,
can be a licensed physician in another state, and does not have to be licensed to
practice in the State of California.


COMMENTS: One of the attacks on IMR decisions made by applicant attorneys
involved the licensing of doctors who performed Independent Medical Reviews. This
Significant Panel Decision, although not binding on the Courts, does allow IMR
doctors who are not licensed to practice in the state of California, but licensed to
practice medicine in other states, to perform Independent Medical Reviews.
It is very much anticipated that the Applicant, in Pro Per, will appeal this decision.
Enjoy your Summer!
Par

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