Joined: Apr 2004
Tuesday November 02, 2004 6:14 AM
This letter was provided to me by a very good friend. (TM) I am sure he has no problem w/ me posting it here for all to use as they see fit. His recommendation is to fax the letter but I intend to fax and send regular mail.
Applicant objects to the decision to modify, and/or delay, and/or deny the medical treatment as recommended by __________________, M.D. in the report dated _________.
Demand is hereby made for the following in the next 15 days:
[X] Written authorization for recommended treatment referred to above;
[X] A reference, in writing, to Administrative Director's medical treatment utilization schedule or A.C.O.E.M. Guidelines on which the denial of treatment is based;
[X] This is a pre- 01-1-04 date of injury, therefore Labor Code Section 4604.5 does not apply. Please provide a written explaination of your denial of treatment based upon applicable Labor Code Section;
[X] Pursuant to Labor Code Section 4610(c), provide a copy of your written policies and procedures and a description of the utilization review process;
[X] Pursuant to Labor Code 4610(d), provide all documentation which demonstrates that the physician you utilized to deny medical treatment is a "licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services,"
[X] pursuant to Labor Code Section 4610(5), provide the criteria or guidelines utilized to deny the treatment requested;
YOU ARE HEREBY NOTIFIED OF THE FOLLOWING:
[x] Your denial of treatment is untimely pursuant to Labor Code Section 4610(g)(1), and (2), and/or (3) A&B. at the hearing of this dispute, we reserve the right to raise such non-compliance/waiver as an issue. In any event, the legislature did not state that Labor Code Sections 4604.5 and 4610 are to have retroactive effect, therefore, said sections are inapplicable to the applicant's date of injury(ies);
[X] As a consequence of the denial of treatment without legal justification, applicant's attrorney will seek attorney's fees pursuant to Labor Code Section 5813 at the appropriate procedural time;
[X] YOU ARE HEREBY NOTIFIED THAT, WITH REFERENCE TO THE ABOVE BENEFITS, THE APPLICANT IS CLAIMING ALL PENALTIES, INTEREST AND ATTORNEY'S FEES PERMITTED BY LAW. PLEASE CONSIDER THIS A REQUEST TO RESOLVE ALL THE ABOVE ISSUES, INCLUDING PENALTIES, INTEREST, ATTORNEY'S FEES, WITHIN THE NEXT 15 DAYS. THEREAFTER, APPLICANT RESERVES THE RIGHT TO FILE A DECLARATION OF READINESS TO PROCEED.
P.S. Sorry I couldn't get the fomat correct. I am sure you get the jist.
I am hoping to see many, many of these letters of objection to UR reviews being sent by ALL my friends here at WCC.
This can also be use as as a guide at the time of trial when asked what are the issues being raised by the parties.
Edited: Wednesday November 03, 2004 at 5:00 AM by Hammer