Once again, State Compensation Insurance Fund (SCIF)  and EK Health  denied surgery for an injured worker by citing unadopted, alternative treatment guidelines outside of California’s designated Medical Treatment Utilization Schedule (MTUS).

With the worker reportedly in severe pain, a physician requested surgery with precise adherence to California workers’ compensation laws, regulations, and rules. In their response, SCIF and EK Health made up their own rules and applied treatment guidelines that kept appropriate treatment out of reach.

Worse, the denial details were a minefield of language seemingly designed to preclude any possibility of Independent Medical Review  (IMR), the only recourse for an injured worker denied care deemed medically necessary by their physician.

The provider’s successful navigation of SCIF and EK Health’s nonsensical roadblocks — at great expense of time and practice administrative resources — is the only reason the surgery was ultimately approved after an agonizing, pointless delay.

As always, the injured worker (forced to endure months of suffering) is the only one on whom the consequences of California’s unregulated, indefensibly broken UR system fall.