Ramirez v. WCABAnnotate this Case
In this writ proceeding, Daniel Ramirez sought review of his independent medical review (pursuant to his workers' compensation claim) on the ground the underlying utilization review was based on an incorrect standard. In effect, he sought review of his utilization review with this the Court of Appeal. The Court concluded this was not a proper ground for appeal of a utilization review determination because "it goes to the heart of the determination of medical necessity. The independent medical reviewer is in the best position to determine whether the proper standard was used to evaluate the medical necessity of the requested treatment, and the statutory scheme requires the independent medical reviewer to use the proper standard in determining medical necessity." Ramirez made no claim that the independent medical reviewer did not use the proper statutory standard, nor did he state a proper ground for review of his independent medical review, which was appealable only for the nonsubstantive reasons. Ramirez also challenged the constitutionality of the independent medical review process, claiming it violated the state Constitution’s separation of powers clause, and state and federal principles of procedural due process. The Court concluded that the Legislature’s plenary power over the workers’ compensation system precluded any separation of powers violation, and the process afforded workers under the system afforded sufficient opportunity to present evidence and be heard.