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UR CANNOT DECERTIFY PRIOR UR APPROVAL
Servin v. Cerritos Lexus (2022) is an interesting Order Denying Reconsideration case involving competing UR decisions. Defense accepted a left shoulder injury, with UR denying a request for surgery due to no supporting imaging studies. The PTP then resubmitted the RFA for surgery, noticing a change in material facts and attached imaging studies. This resulted in UR approving the shoulder surgery.
That should have been the end of the story, except five days later the same UR reviewer then de-certified the same shoulder surgery he had just approved.
The issue of which UR decision applies went to trial, with the defense claiming the first UR denial was valid for 12 months rendering all subsequent UR decisions moot; however, the trial judge ruled the "change of material facts" issue required the defense to resubmit the subsequent RFA to UR, thus making the second UR decision which approved the surgery valid.
On reconsideration, the WCAB agreed with the trial judge that the availability of the imaging studies was a new material fact that allowed for a UR resubmission pursuant to 8 CCR 9792.9.1 (h). Additionally, the Board stated it was "statutorily impermissible" for a final UR approval to be later de-certified.
[COMMENTS: There is no statutory provision allowing for a reversal of a UR approval, even if the UR reviewer discovers a mistake was made.]
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