Getting hurt on duty is difficult enough without having to fight over the treatment your doctor says you need. Yet a physician’s recommendation doesn’t automatically mean work comp will authorize the care. Requests for physical therapy, injections, imaging, surgery, medication, and other treatment may first go through utilization review.
For San Diego firefighters, police officers, deputies, and other first responders, a delay or denial can have consequences beyond discomfort. Your ability to recover may affect when you return to duty, what restrictions you have, and whether you can safely perform the physical demands of your position.
California gives injured workers a process for challenging treatment decisions based on medical necessity. Understanding how utilization review (UR) and independent medical review (IMR) work can help you respond when care gets denied and recognize when you need to seek work comp legal help in San Diego.
What is utilization review in a work comp claim in San Diego?
Utilization review is the process a claims administrator uses to determine whether requested medical treatment is medically necessary.
Your treating physician generally starts the process by submitting a request for authorization that explains the treatment being recommended and the medical reasons for it. The claims administrator then reviews that request under California’s workers’ compensation treatment guidelines.
UR does not always result in a simple yes or no. The reviewer may:
- Approve the treatment as requested
- Modify part of the proposed treatment
- Deny the request based on medical necessity
Why would workers’ comp deny treatment your doctor recommends?
A UR denial usually means the reviewer concluded that the request did not sufficiently establish medical necessity under the applicable treatment guidelines. That does not necessarily mean the reviewer believes you are no longer injured. The dispute may instead center on the particular treatment being requested.
Documentation can make a significant difference. A treatment request that simply states what your doctor wants may leave important questions unanswered. A stronger record explains why the treatment is appropriate for your condition, what has already been tried, and why the proposed care remains medically necessary.
What happens after utilization review denies your treatment?
If UR denies or modifies treatment because it is considered medically unnecessary, independent medical review is generally the process used to challenge that decision.
IMR sends the medical necessity dispute to an independent physician reviewer. That reviewer considers the relevant medical records and treatment guidelines and determines whether the UR decision should stand.
This distinction matters because treatment disputes do not follow the same path as every other disagreement in a workers’ compensation case. A QME may address issues such as the cause of an injury, permanent impairment, or work restrictions, but California generally routes disputes over the medical necessity of treatment through UR and IMR.
What information matters during an IMR?
The medical record matters because the IMR reviewer makes the decision based on the treatment request, supporting documentation, applicable guidelines, and other relevant records. That makes your treating physician’s documentation especially important. Depending on the treatment at issue, useful records may show:
- The symptoms and limitations you continue to experience
- Treatments you have already completed
- Whether earlier treatment improved your condition
- Test or imaging findings that support the request
- Why alternative treatment is not appropriate
- How the requested care relates to your diagnosed work injury
Where can I find work comp legal help in San Diego for a denied treatment request?
When work comp delays, modifies, or denies treatment, the next step can feel unclear. Our team at Golden State Workers Compensation helps first responders understand UR and IMR decisions, review the medical evidence behind a denial, and determine what options remain. If you work in the Downtown area or elsewhere in SD, we can also explain when a QME may resolve conflicting medical opinions in other parts of your claim. If your condition has stabilized but lasting limitations remain, understanding how permanent disability is evaluated after you reach MMI can also help you make the right move.
Call to set up a free case review and consultation at our office, and we’ll show you how we can protect your rights and work comp benefits. Let’s talk today!
