No moment in a comp claim produces more fury than the letter denying the surgery your own doctor ordered. The system that produced it is utilization review — and beating it is about paperwork mechanics, not volume. Here is the machine, plainly.
Every request passes through UR
The treating doctor submits a request for authorization (DWC Form RFA); the claims administrator’s UR program answers on a clock — 5 business days for ordinary requests, 72 hours expedited (§4610). The reviewer is a physician applying the MTUS, California’s evidence-based treatment schedule. This is the part nobody tells injured workers: UR approves most requests. The denials cluster where the RFA is thin — no imaging attached, no documented failure of conservative care, no guideline citation.
The denial letter starts a 30-day clock
Appeal is independent medical review — the application ships with the denial, and you have 30 days to file (§4610.5). IMR is anonymous, paper-only, and binding (§4610.6): a state-contracted physician applies the same MTUS to whatever records are in the file. Most denials survive it. The realistic wins come from two places: UR got the guidelines wrong, or the file was missing records that IMR now gets to see. Which is why the smart response to a denial is often a resubmitted RFA with changed facts — new imaging, progressed symptoms — since a denial only holds 12 months absent changed circumstances.
What UR cannot touch
UR governs treatment. It has no power over your rating — the WPI, apportionment, and work restrictions live in the med-legal lane with the QME, and the money math runs on the calculator regardless of what UR thinks of your surgery. Denied care also doesn’t erase the future-medical award: the award survives; each request still runs the UR gauntlet. Doctor choice upstream of all this: the MPN rules.
Estimates for informational use; not legal or medical advice.
Rate your spine right here
Same engine as the tables above — pick your occupation and age, slide the WPI from the report, and carry it into the full calculator when you’re ready.