State Compensation Insurance Fund (SCIF) and EK Health just can’t seem to get the hang of Utilization Review (UR).

We previously detailed how SCIF and EK Health denied a $98 injection due to a “Lack of Information,” even though EK Health’s own UR decision listed the information that was “lacking.” But this UR decision also offered another forehead-smacking example of just how far off the rails California’s ungoverned UR system has gone.

The UR decision also falsely claimed that California’s Medical Treatment Utilization Schedule (MTUS) does not address the requested treatment. So altogether, SCIF and EK Health’s denial of the treating doctor’s request:

• Was untimely (without consequence)
• Falsely claimed lack of information (without consequence)
• Falsely claimed the MTUS does not support the treatment (without consequence)

The $98 question is precisely how this worker will receive the treatment deemed necessary by their doctor. They probably won’t, and all because EK Health isn’t thorough or informed enough to do their job properly — unless their job is saving SCIF money with dubious denials.

EK Health Concocts False MTUS Claim

To treat a hand and forearm injury stemming from data entry work, the treating doctor submitted a compliant Request for Authorization (RFA) for an injection, along with 20 pages of medical documentation supporting the injection's appropriateness, necessity, and previous effectiveness.

Along with demonstrably false claims of missing information, EK Health’s denial (shown below) noted that the MTUS is “silent” regarding the requested treatment.

Except…

The MTUS is certainly not “silent” on the requested treatment for the injury. As the thorough medical documentation the physician included with the RFA (shown below) explains, the injury involves the “A1 pulley trigger” and “trigger finger tenosynovitis.”

The MTUS guidelines are adopted by the California Division of Workers’ Compensation (DWC) from the American College of Occupational and Environmental Medicine (ACOEM) guidelines. As shown below, the MTUS guidelines on Hand, Wrist, and Forearm Disorders specifically and strongly recommend the requested injection for “triggering digit or symptoms of pain over the A-1 pulley thought to be consistent with stenosing tenosynovitis.”

At daisyBill, we are RFA and electronic billing experts, not physicians; we can’t say whether a given treatment is appropriate. But it doesn’t take a PhD to see that claiming the MTUS has nothing to say about the treatment recommended in this particular RFA isn’t a matter of medical debate — it’s simply bunk.

Why make this absurd, false claim about the MTUS on the UR decision? Is it simply unfathomable incompetence from a URO whose sole function is to weigh treating doctors’ RFAs against the applicable guidelines? Is it laziness? The MTUS is free for California physicians, so it can’t be a budget issue.

What could it be then?

In this case, the false claim of missing information was the primary rationale for the denial. But are EK Health and/or other UROs denying other RFAs based on demonstrably untrue assertions about what the MTUS does or doesn’t say?

More importantly, is anybody (other than daisyBill) checking?

If only California had an entire government agency responsible for policing the behavior of insurers and UROs, to make sure injured workers didn’t suffer because of incompetence or non-compliance.

We could call it the…Division of Workers’ Compensation, or something. Wouldn’t that be grand?

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