What Is a Utilization Review in a California Workers’ Comp Case?

 Posted on October 22, 2026 in Workers' Compensation

When your doctor recommends treatment for a work injury, waiting for insurance approval adds another concern to your recovery. You might wonder why the insurance company needs to review the care your doctor says you need.

Utilization review is the process used to decide whether treatment is medically necessary. It affects whether workers’ compensation will approve that care. If a review is delaying your medical treatment in 2026, our Santa Clara County, CA workers’ compensation attorney will explain your options and help you address the dispute.

How Does Utilization Review Work in California Workers’ Compensation?

Your treating doctor starts the process by sending a request for authorization (RFA). The request explains what care you need and includes medical records supporting it. The company handling your claim compares that request with California’s treatment guidelines. These guidelines explain which treatments are recommended for certain work injuries and when they should be used.

For example, if your doctor requests more physical therapy, the records should explain how earlier sessions helped. They should also describe what further treatment is expected to achieve.

An accepted injury claim does not mean every treatment is approved. Utilization review looks at the care your doctor requests, rather than whether the injury happened at work.

Who Decides Whether Your California Workers’ Comp Treatment Is Approved?

Claims staff are allowed to approve treatment. Under California Code of Regulations, Title 8, Section 9792.9.5, only a doctor is qualified to assess the medical issues involved. It is also up to that doctor to deny the request or approve less care than your own doctor recommended.

The reviewing doctor examines the treatment request and supporting records without taking over your care. Your treating doctor remains responsible for your treatment and is allowed to discuss the decision with the reviewer.

If treatment is denied or changed, you must receive a written decision explaining why. The notice must identify the medical records and guidelines used. If records were missing, it must explain what information was needed.

What Types of Utilization Review Apply to California Work Injuries?

The type of review is based on whether your care has started or has already been provided. The main types are:

• Prospective review: Reviews a request before treatment begins, such as a planned surgery
• Concurrent review: Reviews your care while you are receiving it, such as treatment during a hospital stay
• Retrospective review: Reviews treatment after it has been provided, including certain emergency care

A lack of advance approval alone is not a valid reason to refuse coverage for emergency care needed to stabilize you. That care is subject to review afterward.

An urgent request follows a faster process called expedited review. Your doctor must explain why waiting for a standard decision would threaten your health or harm your condition.

How Long Does Utilization Review Take in California?

For most complete requests made before or during treatment, a decision is due within five business days. According to California Code of Regulations, Title 8, Section 9792.9.3, the decision must come sooner if your condition requires it.

For a qualifying urgent request, the deadline is no more than 72 hours after the reviewer receives the written information needed to decide. This is different from simply asking the company to move faster because an appointment is approaching.

For care reviewed after it was provided, the deadline is 30 days after the request and enough medical information is received. Certain prescription-drug requests have separate timing rules.

The rules allow extensions when the reviewer needs more records, tests, or a medical consultation. Before treating a response as late, check whether the request was complete and whether a valid extension applies.

What Happens if Utilization Review Denies Your Treatment in California?

You have the right to challenge a decision that denies or reduces care because it was found medically unnecessary. The process is called independent medical review, or IMR. A medical professional outside the insurer’s review process decides whether the treatment is needed.

You usually have 30 days from service of the written decision to request IMR. Service means the decision was formally sent to you. A shorter 10-day deadline applies when the decision only concerns a drug on the state’s MTUS Drug List.

To request IMR, submit the signed application and a copy of the denial. Send a copy of the signed application to the company handling your claim as well.

Your doctor should address the reason given for denying care. For example, if the reviewer says you have not tried a required treatment first, records showing that you already tried it could support your challenge. Do not let discussions with the insurer cause you to miss the filing deadline.

What Should You Do if You Receive No Utilization Review Decision?

Ask your doctor’s office when the request was sent and whether it received a response. The office should check whether the reviewer returned the request as incomplete or asked for more records.

If the deadline passed without a valid decision, your attorney should assess whether to request an expedited hearing before the Workers’ Compensation Appeals Board. A judge addresses whether the review was late and, when appropriate, whether the treatment is medically necessary.

Silence does not mean you should schedule care assuming workers’ compensation will pay. Confirm how the delay should be handled before agreeing to pay for treatment yourself.

Contact a Santa Clara County, CA Workers’ Compensation Lawyer

A delay or denial of treatment can leave you struggling to get the care you need to recover. At Raul Martinez Injury Law Firm, our attorney will examine the decision and help you pursue the medical care your work injury requires.

Attorney Raul Martinez has more than 15 years of legal experience. Contact our Morgan Hill, CA workers’ compensation attorney or call 408-848-1113 to schedule a free consultation.