Workers’ Comp Medical Treatment Request

What to Do if Your Workers’ Comp Medical Treatment Request is Denied

Few things are more frustrating than suffering a workplace injury, following all the proper steps to get treatment, and then receiving a denial letter from the insurance company. When a workers’ comp medical treatment request is denied, injured workers often feel helpless and unsure of what to do next. The good news is that a denial is not the end of the road—California law provides clear pathways for challenging these decisions.

The experienced workers’ comp attorneys at Cantrell Green in the Los Angeles area help injured workers fight back against unfair treatment denials. With a thorough understanding of California’s utilization review and appeals processes, the legal team advocates for clients who have been wrongfully denied the medical care they need to recover.

Understanding your options and acting quickly are essential. California imposes strict deadlines on treatment disputes, and knowing how to respond can mean the difference between getting the care you need and being left to struggle without it.

How Utilization Review Affects Your Workers’ Comp Medical Treatment Request

In California, every workers’ comp medical treatment request goes through a process called utilization review. The insurance company’s UR department evaluates whether the requested treatment is medically necessary according to established guidelines, primarily the Medical Treatment Utilization Schedule. A physician working for the UR company reviews the request and issues a decision to approve, modify, delay, or deny the treatment.

When a denial is issued, the insurance company must provide a written explanation stating the specific reasons and citing the medical guidelines relied upon. The denial letter must also include instructions on how to appeal the decision.

The workers’ comp attorneys at Cantrell Green in the Los Angeles area understand how utilization review decisions are made and can quickly identify when an insurance company has improperly denied a treatment request.

Appealing Through Independent Medical Review After a Denied Workers’ Comp Medical Treatment Request

If your workers’ comp medical treatment request is denied through utilization review, California law allows you to request an Independent Medical Review. Established under Labor Code Section 4610.5, the IMR process provides an independent evaluation of treatment disputes by physicians who have no connection to the employer or insurance company.

To initiate an IMR, the injured worker or their attorney must submit an application to the Division of Workers’ Compensation within 30 days of receiving the UR denial. The reviewing physicians evaluate the medical records and documentation without conducting an in-person examination, then issue a binding decision on whether the treatment should be authorized.

The skilled workers’ comp attorneys at Cantrell Green in the Los Angeles area help clients prepare comprehensive IMR applications, ensuring that all relevant medical evidence is submitted to support the request for treatment.

Why Insurance Companies Deny a Workers’ Comp Medical Treatment Request

Insurance companies deny treatment requests for a variety of reasons, though not all denials are legitimate. Common justifications include claims that the proposed treatment is not medically necessary, that the condition is unrelated to the workplace injury, or that less expensive alternative treatments should be tried first. Some denials cite insufficient documentation from the treating physician.

In many cases, denials stem from incomplete or unclear medical reports rather than any genuine problem with the treatment itself. A physician may not have explained the medical necessity in sufficient detail, or the records may not clearly connect the treatment to the industrial injury.

The workers’ comp attorneys at Cantrell Green in the Los Angeles area carefully analyze denial letters to identify weaknesses in the insurance company’s reasoning and develop strategies to overturn unfair decisions.

Building a Strong Appeal After Your Workers’ Comp Medical Treatment Request Is Denied

A successful appeal requires compelling documentation. Injured workers should work closely with their treating physicians to ensure that medical reports clearly explain why the requested treatment is necessary and how it relates directly to the workplace injury. Supporting evidence such as diagnostic imaging, specialist consultations, and detailed treatment histories strengthens the case.

The appeal should directly address each reason the insurance company gave for the denial. If the insurer claimed the treatment was not medically necessary, the response should include medical literature and clinical evidence demonstrating its appropriateness under recognized treatment guidelines.

At Cantrell Green in the Los Angeles area, the workers’ comp attorneys coordinate with medical providers to gather the evidence needed for a persuasive appeal and guide clients through every step of the process.

Critical Deadlines for Disputing a Denied Workers’ Comp Medical Treatment Request

California law imposes strict timeframes throughout the treatment dispute process, and missing a deadline can result in losing important rights. Insurance companies must complete prospective utilization review—requests submitted before treatment is provided—within five business days. Injured workers have just 30 days from the date of a UR denial to request an Independent Medical Review.

These deadlines are firm, and extensions are rarely granted. Acting promptly after receiving a denial is essential to preserving the right to challenge the decision.

The workers’ comp attorneys at Cantrell Green in the Los Angeles area track all deadlines carefully and ensure that appeals are filed on time to protect each client’s rights.

When IMR Decisions Can Be Challenged in Workers’ Comp Medical Treatment Request Disputes

While IMR decisions are generally considered final and binding on the question of medical necessity, limited circumstances exist where they can be appealed. If an IMR decision was based on incorrect information, if a conflict of interest affected the review, or if the reviewing physician failed to follow proper procedures, the decision may be challenged before the Workers’ Compensation Appeals Board.

In Stevens v. WCAB (2015), the court confirmed that IMR decisions are subject to appeal when procedural requirements have not been met. Identifying these exceptions requires careful legal analysis of both the IMR process and the specific facts of the case.

The experienced workers’ comp attorneys at Cantrell Green in the Los Angeles area evaluate each case to determine whether grounds exist to challenge an unfavorable IMR decision and pursue all available remedies on behalf of their clients.

Workers’ Comp Attorneys | Los Angeles Area

If your request for medical treatment has been denied, you have options—and you do not have to fight alone. The attorneys at Cantrell Green in the Los Angeles area are dedicated to helping injured workers obtain the medical care they need and deserve. With extensive experience handling utilization review disputes, IMR applications, and appeals, the team understands how to effectively challenge wrongful denials. Contact Cantrell Green today to discuss your situation and learn how to move forward with your treatment dispute.

Los Angeles Area Top Workers Comp Attorneys: 800-964-8047