Find out how a new California ruling could shake up your workers’ comp claims handling strategy

California’s appellate court just ruled: only medical professionals – not the WCAB – can decide ongoing workers’ comp treatment disputes after a utilization review denial.

On November 10, 2025, the California Court of Appeal, Second Appellate District, Division Three, issued its decision in Illinois Midwest Insurance Agency LLC v. Workers’ Compensation Appeals Board and Orlando Rodriguez. The case clarifies who has authority over disputes about continued medical care for injured workers in California.

The dispute started after Orlando Rodriguez, a mechanic, suffered significant head and brain injuries at work in 2016. His employer’s insurer, Procentury Insurance Company, administered by Illinois Midwest Insurance Agency, accepted the injury as work-related. Beginning in September 2018, Rodriguez’s doctor, Dr. Yong Lee, requested home health care services for Rodriguez in six-week increments. Illinois Midwest approved several requests, sometimes after sending them to utilization review, where a medical professional determines if treatment is medically necessary.

In September 2019, Dr. Lee’s request for additional home health care was denied by a utilization review physician. Rodriguez challenged the denial before a workers’ compensation judge, who found Rodriguez was entitled to ongoing home health care and concluded Illinois Midwest could not terminate treatment without showing a substantive change in Rodriguez’s condition. The judge relied on Patterson v. The Oaks Farm, a non-binding Appeals Board decision, to support the ruling.Illinois Midwest filed for reconsideration, arguing that the Workers’ Compensation Appeals Board (WCAB) lacked jurisdiction to decide ongoing medical necessity disputes after a utilization review denial. The Appeals Board affirmed the judge’s decision, again relying on Patterson.

The appellate court reviewed the case and examined legislative reforms from 2004 and 2013. The court noted these reforms were designed to ensure that disputes over medical necessity are decided by medical professionals through utilization review and, if necessary, independent medical review – not by the WCAB or courts.

The court held that there is no exception for ongoing or continual treatment. If a request for authorization is denied through utilization review, the only way to challenge that denial is through independent medical review, as required by statute. The court rejected the reasoning in Patterson to the extent it conflicted with the statutory framework.

The court annulled the Appeals Board’s decision and remanded the matter for further proceedings consistent with its opinion. The decision did not discuss specific insurance policy clauses, as the dispute was about statutory procedures, not policy interpretation.

The ruling means that disputes over ongoing medical treatment in California workers’ compensation cases must follow the statutory utilization review and independent medical review process. The WCAB cannot decide medical necessity once a utilization review determination has been made.

This decision reinforces the exclusive role of medical professionals in determining the medical necessity of ongoing treatment under California’s workers’ compensation laws.