Utilization Review: How California Decides Whether You Get Treatment

Verified against the regulations — August 19, 2026

The April 1, 2026 restructure is confirmed from the regulation text itself. 8 CCR § 9792.9.1 carries the note "Amendment of section heading, section and Note filed 12-30-2025; operative 4-1-2026 (Register 2026, No. 1)", and § 9792.9.8 carries "New section filed 12-30-2025; operative 4-1-2026."

The Office of Administrative Law approved the package on December 30, 2025, and the DWC describes it as implementing the SB 1160 exemption for treatment in the first 30 days and the AB 1124 formulary provisions, enforcing the UR accreditation requirement, and amending the UR investigation rules.

The hard five-day formulary clock is confirmed verbatim. § 9792.9.8(b)(3): "The extension of time as set forth in section 9792.9.6 is not applicable to a request for authorization of a drug covered under this subdivision."

Your doctor recommended treatment. A company you have never heard of, hired by your employer's insurance carrier, decided you do not need it.

That is utilization review. It is legal, it is mandatory, and it happens roughly two hundred thousand times a year in California. This page explains exactly how it works, every deadline that governs it, and — most usefully — the procedural defects that make a denial invalid.

Start here if your treatment was just denied. Two clocks are running. If your dispute is only about a drug on the MTUS Drug List, you have 10 days to file for Independent Medical Review. Everything else is 30 days. Both run from the date the denial was served, not the date you opened it. Miss the window and the denial becomes permanent.

The one exception that saves cases: if the claims administrator failed to send you the IMR application form and addressed envelope with the denial, the clock never started (Labor Code § 4610.5(h)(3)). Check the envelope before you assume you are late.

Everything you have read about California UR before 2026 cites the wrong rules

On April 1, 2026, the utilization review regulations were restructured completely. The old single mega-regulation, 8 CCR § 9792.9.1, was broken into eight separate sections — §§ 9792.9.1 through 9792.9.8. The rulemaking was approved by the Office of Administrative Law on December 30, 2025.

This matters practically. Most law firm pages, most published commentary, and most adjuster form letters still cite regulation numbers that no longer contain what the author says they contain.

A second, older error is even more common: the rule that only a physician may deny treatment is frequently cited to Labor Code § 4610(e). SB 1160 rewrote and re-lettered § 4610 effective January 1, 2018. The rule now lives at § 4610(g)(3)(A). Subdivision (e) today concerns a physician's failure to file a § 6409 report — something else entirely.

If your denial letter cites the old sections, that alone does not invalidate it. But it tells you something about how carefully the file is being handled.

How the process actually runs

1. Your doctor files an RFA. A Request for Authorization, DWC Form RFA, goes to the claims administrator. Under the new § 9785(h), secondary treating physicians may now file RFAs — a meaningful change for workers seeing specialists.

2. The clock starts. The first day of counting is the first normal business day after receipt of a complete RFA (8 CCR § 9792.9.3(a)) — except where the timeline is measured in hours, which is counted from receipt.

3. A reviewer decides. Approvals may be issued by non-physicians. Only a licensed physician may modify, delay, or deny (LC § 4610(g)(3)(A)), and the reviewer must be competent to evaluate the specific issue. Your treating physician is entitled to reach a peer by telephone during California business hours to discuss the request, a modification, or the information needed to decide — § 4610(n) requires the employer or insurer to maintain that access. It is an access duty on them, not a duty on the reviewer to call before denying.

4. You are notified. And then the appeal clock starts.

Every UR deadline

Decision deadlines

Notice deadlines

How long a denial binds you

A decision to modify or deny stays effective as to the same treatment by the same physician — or another physician in the same practice group — for 12 months, unless there is a documented change in the facts material to the basis of the decision (LC § 4610(k)).

That last clause is the whole game on a re-request. A new RFA that restates the same clinical picture will be denied again on the twelve-month rule. A new RFA documenting a genuine change — failed conservative care, new imaging, new objective findings — is a new request. In Medina v. Ajob Staffing (WCAB panel, April 6, 2026), a physician's report was held insufficient because it "merely restated prior opinions without identifying new diagnostic evidence or clinical changes."

The April 1, 2026 overhaul

Five changes matter to injured workers.

1. Some treatment in the first 30 days no longer needs prior authorization

Labor Code § 4610(b) has been on the books since 2018 but was never implemented by regulation. New 8 CCR § 9792.9.7 is the operating rulebook.

For dates of injury on or after January 1, 2018, treatment rendered within 30 days of the initial date of injury is authorized without prospective UR — if all five conditions are met:

1. The body part or condition has been accepted as compensable;
2. The treatment is consistent with the MTUS;
3. The treating physician timely submits DIR Form 5021 (Doctor's First Report) setting out the anticipated treatment plan;
4. All anticipated treatment for those 30 days, including exempt drugs, is set out in an RFA; and
5. Bills are submitted within 30 days of service (180 days for emergency treatment).

The Form 5021 and the complete RFA must both be submitted within five days of your first visit. The clock runs from the initial date of injury — not the claim filing date, not the first medical visit, not the acceptance date. For cumulative trauma, the date of injury under LC § 5412 governs.

Eight categories still require prior authorization even inside the 30 days (§ 9792.9.7(b)): pharmaceuticals not expressly exempt under the formulary; non-emergency surgery in any setting; psychological and psychiatric treatment; home health care; imaging and radiology excluding X-rays; durable medical equipment costing more than $250; electrodiagnostic testing including EMG and nerve conduction studies; and spinal injections — medial branch blocks, facet joint, intradiscal, epidural, and sacroiliac.

That last one is new in the regulation and does not appear in the statutory list. DWC added it under its § 4610(c)(8) authority. It is also, as the data below shows, the category where denials are upheld most often.

2. Non-exempt formulary drugs get a hard five-day clock

For a non-exempt drug on the MTUS Drug List, the decision is due in 5 business days and the extension provision is expressly inapplicable (§ 9792.9.8(b)(3)). If the reviewer wants more information, the request must go out within 4 business days, and if the information does not arrive within 5 business days of that request, denial is permitted — but the underlying 5-day deadline never moves.

A claims administrator that invokes an extension on a non-exempt formulary drug has produced an untimely UR by operation of the regulation, on the face of its own letter. That is worth reading denial letters closely for.

One tactical note for treating physicians: because a bundled drug-and-non-drug RFA reverts to the standard extendable timeline (§ 9792.9.8(d)), a drug request should be submitted on its own RFA.

3. Drug disputes move to a ten-day IMR window

If your dispute involves only drugs on the MTUS Drug List, you have 10 days, not 30, to file for IMR. The claims administrator then has 10 days to submit records, and the determination issues in 5 working days (§ 4610.6(d) says working days, not business days — the UR clocks above are the regulation's business days, and the two are not the same count).

This is the most dangerous deadline in California workers' compensation for an unrepresented worker. Ten days, running from service of a denial letter that may sit unopened for a week. The revised DWC Form IMR (Rev. 04/01/2026) now carries checkboxes identifying whether the 10-day or 30-day deadline applies, plus a mailing-date field. Before April 2026 there was no such flag.

4. Secondary treating physicians may file RFAs

Under amended § 9785(h). Previously a recurring source of delay when a specialist's recommendation had to be routed back through the primary treating physician.

5. Real penalties, and no more waiver

The performance-rating penalty waiver is eliminated. The new schedule at 8 CCR § 9792.12 includes penalties of $250 per day up to $5,000 and $250 per hour up to $18,000 for expedited-review failures. Failing to attach the IMR form to a denial now carries a $2,000 penalty, with additional per-field penalties for an incomplete form.

Separately, amended § 9767.6(f) requires the claims administrator to deliver your medical records, MPN identification, and RFA/billing contacts to your selected treating physician within 20 days of notice of the selection.

What makes a denial invalid

This is the part that decides cases.

Under Dubon II (WCAB en banc, 2014), a UR decision that is untimely is invalid, and the medical necessity dispute goes to a workers' compensation judge rather than to IMR. Stevens v. WCAB (2015) 241 Cal.App.4th 1074 upheld the constitutionality of IMR generally but left timeliness intact as a question the Board decides.

Timeliness is now essentially the whole ballgame — and it is a genuinely winnable one.

Giron v. KDF Forestry (WCAB panel, April 6, 2026) is the case to know. The RFA was received September 4, 2025. The decision was due September 11 — five business days. The employer made telephone calls to the treating physician and treated the request as extended to fourteen days. The panel reversed the trial judge and held the UR untimely: phone calls "did not automatically extend the deadline to 14 days under current law," and the employer failed to provide the written notice of missing information required by Labor Code § 4610(j)(2). With UR invalid, the Board decides medical necessity.

What to look for in your own denial letter:

• Was the decision made within 5 business days of a complete RFA?
• If an extension was taken, was written notice given within 5 business days — or was it handled by phone?
• Was the decision communicated to your doctor within 24 hours, and to you within 2 business days?
• Was the denial signed by a physician? A non-physician may approve; only a physician may deny.
• Was the reviewer competent in the relevant specialty?
• Was telephone access to a peer reviewer actually available to your doctor during business hours (§ 4610(n))? — note this is an access obligation, so its absence is evidence of a defective process rather than an automatic defect in the decision
• Was the IMR application form and addressed envelope enclosed? If not, your appeal clock never started.
• On a non-exempt formulary drug, was an extension asserted at all? It is not available.

Note one preserved argument most practitioners miss. The 14-day outer limit runs from two different events depending on which text you read. Labor Code § 4610(i)(1) says "in no event more than 14 days from the date of the medical treatment recommendation by the physician." The regulation, 8 CCR § 9792.9.6(c)(1), says fourteen days "from receipt of the completed or accepted request." The physician's recommendation almost always predates receipt. Where an RFA sat in a mailroom or clearinghouse, the statutory reading can make a decision untimely that the regulation would call timely. Preserve it.

The MTUS, and how a doctor rebuts it

Treatment is measured against the Medical Treatment Utilization Schedule, which incorporates ACOEM and other evidence-based guidelines and carries a presumption of correctness under Labor Code § 4604.5.

The presumption is rebuttable — by a preponderance of scientific medical evidence establishing that a variance is reasonably required. In practice, rebutting means the treating physician must cite the guideline, explain specifically why this patient falls outside it, and support the variance with evidence. An RFA that simply asserts the treatment is necessary will lose to the guideline every time.

The MTUS is updated on a rolling basis. A hearing was held June 5, 2026 on adopting the January 2026 ACOEM Ankle & Foot (§ 9792.23.7) and Hip & Groin (§ 9792.23.10) guidelines.

Expedited review

Expedited UR — a 72-hour decision — applies where the standard timeframe would be detrimental to your life or health, or would jeopardize your ability to regain maximum function.

Here is the number worth sitting with: in 2025, of 152,351 IMR determinations issued statewide, 108 were expedited. That is 0.07%.

Expedited review exists. It is almost never used. If your situation genuinely qualifies, it has to be requested and documented as such, in writing, by your physician — it will not happen on its own.

What to do the day your treatment is denied

1. Find the envelope and the service date. Everything runs from service, not receipt.
2. Check whether the IMR form and addressed envelope were enclosed. If not, the clock has not started (LC § 4610.5(h)(3)).
3. Determine whether it is a drug-only dispute. If yes, you have 10 days, not 30.
4. File the IMR application. Do not wait for anyone to do it for you.
5. Send the denial letter to your treating physician and ask two things: whether the clinical picture has materially changed, and whether the request should be resubmitted with MTUS citation and a documented rebuttal.
6. Get the letter reviewed for timeliness. This is the single highest-value thing a lawyer does at this stage, and it takes minutes.
7. Keep treating if you safely can. Denial of authorization is not a medical instruction.

Frequently asked questions

What people actually ask about denials

• What if I need surgery?and what to do when the authorization stalls
• They denied my MRI.
• They approved part of my treatment.a partial approval is a denial of the rest, and it starts the same clock
• I need surgery and they're stalling.
• I got an IMR decision.