This case involves an injured worker who sued the utilization review (UR) physician and third-party UR company after he suffered seizures and injuries after the defendants denied coverage for a drug he was prescribed as no “medically necessary” and ordered the treatment be terminated. 

CMA filed an amicus brief in support of the injured worker to address the issue before the California Supreme Court on whether the UR doctor owes a duty of care to the injured worker. CMA’s brief impresses upon the Court how serious and prevalent the problems with UR can be and focuses on the conclusions of CMA, the AMA, the Medical Board of California, and provisions of the Medical Practice Act that state UR by a physician is the practice of medicine. The brief argues that as such, a UR physician owes the same duties of care and obligations as any other physician who practices medicine. That is not to say that there is one standard of care for all physicians. Rather, determining a UR physician’s duties depends on the facts of each case. CMA’s brief also recounts the history of UR in workers’ compensation, explaining to the Court that legislative reforms have elevated the prevalence of UR while also displacing independent physician judgment in favor of mechanical applications of a medical treatment schedule. The brief also presents numerous real-world stories about injured workers being harmed by improper UR decisions. The Court of Appeal heard oral arguments from the parties on May 29, 2018.