When you’re injured at work, getting timely medical care shouldn’t feel like a battle. Unfortunately, in California’s workers’ compensation system, even prescribed treatments must pass through a process called utilization review (UR).
This can delay or deny care, leaving injured workers confused, frustrated and stuck waiting. Understanding how UR works and what you can do when it blocks your recovery is key to protecting your health and your rights.
What is a utilization review?
It is a mandatory process where a claims administrator evaluates whether a recommended treatment is medically necessary. It’s based on California’s Medical Treatment Utilization Schedule (MTUS), which outlines evidence-based guidelines for common injuries. UR decisions must be made within strict timeframes — usually five business days for non-urgent requests.
Why treatment gets denied
Even if your doctor believes a treatment is necessary, UR reviewers (who are often physicians hired by the insurance company) may deny it if it doesn’t align with MTUS guidelines. Common reasons include lack of documentation, experimental procedures and treatments not supported by recent medical evidence.
What injured workers can do
If your treatment is denied, you have the right to request an Independent Medical Review (IMR). This is a separate process where a neutral physician reviews the UR decision. You must submit the IMR request within 30 days of receiving the denial. While IMR decisions are generally final, they can sometimes be challenged in court under limited circumstances.
Protecting your recovery
Navigating UR and IMR can be overwhelming, especially when your need for care is urgent. If your treatment has been delayed or denied, it may be time to learn about your legal options and fight for the care you deserve.