Denied Medical Treatment in San Diego Workers’ Compensation

How Utilization Review Works in California

Every request for medical treatment in the California workers’ compensation system must pass through utilization review before it can be approved. When your treating physician determines you need a specific procedure, medication, or course of care, they submit a Request for Authorization to the claims administrator handling your case.

The claims administrator can approve that request directly or refer it to utilization review under California Labor Code section 4610. When it goes to review, the requested treatment is evaluated against the Medical Treatment Utilization Schedule and other evidence-based guidelines. Reviewers have fixed statutory timelines to approve, modify, or deny the request. A modification might approve a shorter course of care than your doctor recommended. A denial rejects the treatment outright.

The Independent Medical Review Appeal Process

A utilization review denial isn’t necessarily the end. California law gives injured workers the right to request an Independent Medical Review, but the filing deadlines are firm. The standard deadline is generally 30 days from the date of the utilization review determination. Disputes involving only a medication on the Medical Treatment Utilization Schedule Drug List carry a shorter 10-day deadline.

IMR applications are reviewed by Maximus Federal Services, the independent organization contracted by the state to conduct these reviews. A physician reviewer examines the submitted records and generally decides whether to uphold or overturn the utilization review decision within 30 days of receiving the completed application and supporting documentation.

IMR decisions carry significant weight. If the reviewer finds the treatment medically necessary, the claims administrator must authorize it promptly. If the reviewer upholds the denial, that decision is binding. Challenging an IMR outcome at the Workers’ Compensation Appeals Board is possible only on narrow grounds: fraud, a material conflict of interest on the part of the medical reviewer, prohibited bias, or a plainly erroneous mistake of fact. Disagreement with the medical reasoning itself isn’t a recognized basis for appeal.

Why Treatment Requests Get Denied

Insurers most commonly deny or modify treatment requests by arguing the care isn’t medically necessary, that it’s experimental, that it’s requested more frequently than guidelines permit, or that the proposed approach doesn’t align with the applicable treatment schedule. Prescription medication requests are among the most frequently disputed categories at the IMR stage.

A 2025 California Workers’ Compensation Institute review of 1.57 million IMR decision letters issued from 2015 through March 2025 found that nearly 90 percent of utilization review denials were upheld on independent review statewide. That figure describes a systemic pattern, not a prediction about any individual case. How a treatment request is documented, submitted, and supported matters.

Options After an IMR Decision in San Diego

Workers’ compensation disputes for the San Diego area are heard at the Division of Workers’ Compensation’s San Diego district office. When an IMR decision goes against a worker, the path forward depends on the specific facts of the determination.

We review utilization review and IMR determinations for procedural issues, including missed statutory deadlines on the insurer’s side, that can support a challenge at the Workers’ Compensation Appeals Board. The most successful WCAB challenges have relied on jurisdictional or procedural grounds rather than the medical reasoning behind a denial. Missing the IMR filing deadline generally forfeits the right to appeal that specific determination, though submitting a fresh Request for Authorization for the same treatment can produce a new utilization review decision and preserve a second opportunity. The right approach depends on the timeline and the specifics of the denial, which is why early legal review matters.