Zuniga v. Workers' Comp. Appeals Bd. ( 2018 )

Filed 1/23/18 (mod.); pub. order 1/25/18 follows unmodified opinion (attached)
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA
FIRST APPELLATE DISTRICT
DIVISION TWO
SAUL ZUNIGA,
Petitioner,
A143290
v.
WORKERS’ COMPENSATION (WCAB No. ADJ2563341)
APPEALS BOARD, INTERACTIVE
TRUCKING, INC., et al.,
Respondents.
BY THE COURT:
It is ordered that the opinion filed herein on January 12, 2018, be modified as
follows: On page 12, the last paragraph in section B of the Discussion is changed to: “In
sum, section 4610.6, subdivision (f) prevents the Board from ordering an IMR
organization to disclose the names of IMR reviewers, and we therefore reject Zuniga’s
various arguments to the contrary.” Footnote 11 remains at the end of the paragraph.
This modification does not change the judgment.
Dated: _______________________ ___________________________
Kline, P.J.
1
Filed 1/12/18 Zuniga v. WCAB CA1/2 (unmodified opinion)
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA
FIRST APPELLATE DISTRICT
DIVISION TWO
SAUL ZUNIGA,
Petitioner,
A143290
v.
WORKERS’ COMPENSATION (WCAB No. ADJ2563341)
APPEALS BOARD, INTERACTIVE
TRUCKING, INC., et al.,
Respondents.
As a result of amendments to California’s workers’ compensation law that took
effect in 2013, an injured worker may challenge a decision denying medical treatment by
requesting a determination of medical necessity from an independent medical review
(IMR) organization. (Lab. Code, §§ 139.5, 4610.5.1) The IMR organization, which is
regulated by the Division of Workers’ Compensation of the Department of Industrial
Relations (Division) and operates under contract with the administrative director of the
Division, designates one or more medical professionals to review pertinent medical
records, determine whether the disputed treatment is medically necessary, and prepare a
written report including statutorily-required findings to support the reviewer’s
determination. (§ 139.5, subd. (a)(1), § 4610.6, subds. (a) through (e); Cal. Code Regs.,
tit. 8, § 9792.10.1 et seq.) The determination of the IMR organization is deemed to be the
1
Further undesignated statutory references are to the Labor Code.
1
determination of the administrative director, and is binding on all parties, subject to
appeal on narrow statutory grounds. (§ 4610.6, subds. (g) & (h).)
Of significance to the matter before us, the IMR organization is required by statute
to describe the qualifications of the medical professionals who prepare the determination
of medical necessity and to keep the names of the reviewers confidential in all
communications outside the IMR organization. (§ 4610.6, subd. (f).)
Petitioner Saul Zuniga availed himself of the IMR process and then petitioned the
Workers’ Compensation Appeals Board (Board) to disclose the names of the reviewers.
When the Board declined to do so, citing section 4610.6, subdivision (f), Zuniga filed this
writ petition contending that the statute does not prohibit the Board from ordering
disclosure and that any contrary reading violates due process. We granted Zuniga’s
petition for writ of review and now affirm the Board.
FACTUAL AND PROCEDURAL BACKGROUND
A. Background on Worker’s Compensation
To provide context, we summarize the relevant aspects of workers’ compensation
procedure as it exists in the wake of major reforms that took effect in 2004 and 2013,
drawing on the account by our colleagues in Division One in Stevens v. Workers’ Comp.
Appeals Bd. (2015) 241 Cal.App.4th 1074, 1081 (Stevens).)
An injured worker’s physician “submits a treatment recommendation that is
reviewed under the employer’s UR [utilization review] process. (§ 4610.) A ‘medical
director’ designated by the employer or insurer reviews all information ‘reasonably
necessary’ to determine whether to approve, modify, or deny the recommendation.
(§ 4610, subd. (d).) . . . [¶] A UR decision favoring the worker becomes final, and the
employer is not permitted to challenge it. (See § 4610.5, subd. (f)(1).) But if the UR
decision modifies, delays, or denies a request, the worker may seek review through an
IMR. (§ 4610.5, subd. (d).) In other words, the IMR process gives workers, but not
employers, a second chance to obtain a decision in their favor.” (Stevens, supra, 241
Cal.App.4th at p. 1090, fn. omitted.)
2
“The IMR is performed by an independent review organization, which assigns
medical professionals to review pertinent medical records, provider reports, and other
information submitted to the organization or requested from the parties. (§ 4610.6, subd.
(b).) The physician reviewer must approve the requested treatment if it is ‘medically
necessary based on the specific medical needs of the employee and the standards of
medical necessity as defined in subdivision (c) of Section 4610.5.’ (§ 4610.6, subd. (c).)
The IMR determination must state whether the disputed service is medically necessary,
identify the employee’s medical condition and the relevant medical records, and set forth
the relevant findings associated with the standards of medical necessity. (§ 4610.6, subd.
(e).) These standards include, in the order listed in the statute: (1) the [Medical
Treatment Utilization Schedule, which was adopted in 2007 and since updated], (2) peer-
reviewed scientific and medical evidence regarding the effectiveness of the disputed
treatment; (3) nationally recognized professional standards; (4) expert opinion; and (5)
generally accepted standards of medical practice. (§ 4610.5, subd. (c)(2).) If multiple
medical professionals review a case, a majority must agree on the final decision, and if
they are evenly split, the decision must favor the worker. (§ 4610.6, subd. (e).)
Decisions must include the reviewing medical professionals’ qualifications, but the
independent review organization is to ‘keep the names of the reviewers confidential in all
[outside] communications.’ (§ 4610.6, subd. (f).) The IMR determination is deemed as a
matter of law to constitute the determination of the director [the administrative director of
the Division] and is binding on all parties. (§ 4610.6, subd. (g).)
“A worker who disputes the IMR determination may appeal it to the Board.
(§ 4610.6, subd. (h).) . . . [T]he only specified grounds for relief . . . are that the director
acted without authority, the decision was procured by fraud, the physician reviewer had a
material conflict of interest, the decision was the result of bias, or the decision was based
on a plainly erroneous fact that is not a matter subject to expert opinion. (§ 4610.6, subd.
3
(h).)[2] If the Board reverses the decision . . . it may only remand the case for a new IMR.
(§ 4610.6, subd. (i).)”3 (Stevens, supra, 241 Cal.App.4th at pp. 1090-1091.) The new
IMR is to be performed by a different independent review organization, but if a different
organization is not available, as will be the case if there is only one authorized IMR
organization, the new IMR is to be performed by a different reviewer in the organization
that performed the previous IMR. (§ 4610.6, subd. (i).)
“Finally, a Board decision can . . . be challenged by filing a writ of review in the
Court of Appeal. (§ 5950.) . . . [A]ppellate courts are . . . explicitly precluded from
making ‘a determination of medical necessity contrary to the determination of the
independent medical review[er]’ (§ 4610.6, subd. (i)) . . . .” (Stevens, supra, 241
Cal.App.4th at p. 1091.)
2
Section 4610.6, subdivision (h) states: “A determination of the administrative
director pursuant to this section may be reviewed only by a verified appeal from the
medical review determination of the administrative director, filed with the appeals board
. . . and served on all interested parties within 30 days of the date of mailing of the
determination to the aggrieved employee or the aggrieved employer. The determination
of the administrative director shall be presumed to be correct and shall be set aside only
upon proof by clear and convincing evidence of one or more of the following grounds for
appeal: [¶] (1) The administrative director acted without or in excess of the
administrative director’s powers. [¶] (2) The determination of the administrative director
was procured by fraud. [¶] (3) The independent medical reviewer was subject to a
material conflict of interest that is in violation of Section 139.5. [¶] (4) The
determination was the result of bias on the basis of race, national origin, ethnic group
identification, religion, age, sex, sexual orientation, color, or disability. [¶] (5) The
determination was the result of a plainly erroneous express or implied finding of fact,
provided that the mistake of fact is a matter of ordinary knowledge based on the
information submitted for review . . . and not a matter that is subject to expert opinion.”
3
Although an employer cannot dispute a UR decision that is favorable to an
employee (§ 4610.5, subds. (d) & (f)(1)), nothing in the statute prohibits an employer
from disputing an IMR determination. (See § 4610.6, subd. (h) [referring to “the
aggrieved employee or the aggrieved employer” in authorizing appeals from IMR
determinations].)
4
B. Reviews of Zuniga’s Treatment Plan
Zuniga’s employer, Interactive Trucking, Inc., was insured for workers’
compensation by the State Compensation Insurance Fund (State Fund).4 After a work-
related injury to his left shoulder in 2007, Zuniga underwent several surgical procedures.
He was left with continuing pain, and as of 2013 he had for several years been a patient
of a pain-management specialist, Dr. Grant, who administered and monitored several
medications. Zuniga’s pharmaceutical regimen changed little from about 2011 to 2013,
when State Fund submitted Dr. Grant’s prescriptions for utilization review. The result
was that one of the five prescriptions was approved and the other four were denied.
Zuniga appealed the decision through the IMR process. As part of that process,
State Fund sent relevant documents to the IMR organization, Maximus Federal Services
(Maximus). The result of the IMR was a “Final Letter of Determination” approving one
of the four previously rejected prescriptions and rejecting the other three.
Zuniga filed a timely appeal, alleging that the IMR decision resulted from
erroneous factual findings. After a hearing, the administrative law judge found that each
of the IMR denials was based on a plainly erroneous finding of fact, and on that basis
reversed the IMR decision. Because Maximus was the only authorized IMR organization
during the pendency of the case, the matter was remanded to Maximus for review by a
different reviewer.
On February 25, 2014, while the second IMR was in process, Zuniga filed a
petition asking the Board to order the IMR organization to disclose the identities of the
first and second IMR reviewers to the parties or to the judge. Although the second IMR
had not been completed, Zuniga argued that it is a denial of due process for an IMR to
refuse to disclose the identities of the reviewers when the decision of the first reviewer is
4
State Fund is an entity established by the Legislature, “ ‘at once both an agency
of the state and an insurance carrier.’ ” (California Attorneys v. Brown (2011) 195
Cal.App.4th 119, 124, quoting P.W. Stephens, Inc. v. State Compensation Ins. Fund
(1994) 21 Cal.App.4th 1833, 1835.) State Fund claims to be the state’s largest provider
of workers’ compensation insurance.
( [as of Jan. 12, 2018].)
5
reversed and the dispute is referred to a different reviewer in the organization, claiming
that without knowing the identities of the reviewers, an applicant is deprived of the
opportunity to “dispute the findings of the second reviewer on the ground that they were
made by the same reviewer whose opinion was reversed.” Zuniga argued that if the same
reviewer wrote both reports, then the IMR could be challenged on the ground that
director would have acted outside his authority (§ 4610.6, subd. (h)(1)) because the
prohibition against using the same reviewer would be violated. (§ 4610.6, subd. (i).) He
also argued that if the same reviewer wrote both reports, the determination might well
have been procured by fraud (§ 4610.6, subd. (h)(2)), and the reviewer might have a
material conflict of interest (§ 4610.6, subd. (h)(3)) because he or she would be reviewing
his or her own prior decision.
Before Zuniga’s petition was heard, Maximus issued a second IMR determination,
labeled a “Final Determination After Re-Review,” stating that it “was the product of a
complete re-review conducted pursuant to a court order,” and “was performed by a
medical reviewer who was not associated with the original review.” This time, the IMR
approved two of the four prescriptions that had been rejected in the utilization review,
and disapproved the other two.5 Zuniga did not appeal the second IMR determination.
A hearing on Zuniga’s petition to learn the identities of the IMR reviewers was
held in May 2014. In June the administrative law judge issued his findings and order,
concluding that in view of the confidentiality provision of section 4610.6, subdivision (f),
he was required to deny Zuniga’s request to compel Maximus to disclose the identities of
the reviewers.
Zuniga petitioned for reconsideration, arguing that the statute did not prohibit the
Board from ordering Maximus to identify the reviewers, and that the “secrecy provision”
5
Despite this different result, and despite the fact that the two IMRs offer different
rationales for their decisions disapproving medications, at oral argument Zuniga’s
counsel characterized the two IMR determinations as “virtually the same.” Zuniga points
to nothing in the record that suggests the two IMR determinations were prepared by the
same physician.
6
of section 4610.6, subdivision (f) “when read within the statute as a whole, can only be
said to apply until the IMR decision is successfully challenged.” The administrative law
judge issued a report and recommendation that reconsideration be denied, which was
adopted by the Board.
Zuniga timely filed a petition for a writ of review as authorized by section 5950.6
After briefing was completed, we issued a writ of review and directed Zuniga to serve a
copy of his petition on the administrative director of the Division, who then filed an
informal opposition.7 We subsequently granted the California Worker’s Compensation
Institute’s unopposed application to file an amicus curiae brief in support of respondent
State Compensation Insurance Fund, and also granted an unopposed request from
respondents Interactive Trucking, Inc. and State Fund that we take judicial notice of some
legislative history materials.8
6
State Fund argues that because Zuniga has not appealed the second IMR
determination, he lacks standing to file a petition for a writ of review. But Zuniga is
aggrieved by, and seeks review of, the Board’s denial of his request for the identities of
the IMR reviewers, which he made on the basis of the result of the first IMR
determination. It may be that Zuniga’s appeal is moot: even if we conclude that the
Board should have ordered the IMR organization to disclose the names of the reviewers
who prepared the first and second IMR determinations, it is unclear what effective relief
we would be providing, because Zuniga did not appeal the second IMR determination,
and the time to appeal it has passed. (Eye Dog Foundation v. State Board of Guide Dogs
for the Blind (1967) 67 Cal.2d 536, 541 [an appeal will be dismissed as moot when the
appellate court cannot grant effective relief]; § 4610.6, subd. (h) [appeal must be served
within 30 days of the mailing of the IMR determination].) Nevertheless, we address the
merits of Zuniga’s petition because the issue is likely to recur between the parties. (Los
Angeles International Charter High School v. Los Angeles Unified School Dist. (2012)
209 Cal.App.4th 1348, 1354 [“an exception to the mootness doctrine is the distinct
possibility that the controversy between the parties may recur”].)
7
Accordingly, to the extent there is merit to State Fund’s arguments that the
administrative director did not receive proper notice of Zuniga’s petition and should have
been included as a party, those arguments are moot.
8
Interactive Trucking, Inc. and State Fund gave notice under California Rules of
Court, rule 8.254 of two authorities issued after the parties completed their briefing:
Stevens, supra, 241 Cal.App.4th 1074, and Ramirez v. Workers’ Comp. Appeals Bd.
(2017) 10 Cal.App.5th 205 (Ramirez). Stevens is discussed in the administrative
7
DISCUSSION
A. Applicable Law and Standard of Review
We interpret workers’ compensation statutes de novo, while giving great weight to
the Board’s interpretation. (Coca-Cola Enterprises, Inc. v. Workers’ Comp. Appeals Bd.
(2011) 194 Cal.App.4th 809, 815.)
“A fundamental rule of statutory construction is that a court should ascertain the
intent of the Legislature so as to effectuate the purpose of the law. [Citations.] In
construing a statute, our first task is to look to the language of the statute itself.
[Citation.] When the language is clear and there is no uncertainty as to the legislative
intent, we look no further and simply enforce the statute according to its terms.
[Citations.] [¶] Additionally, however, we must consider [statutory language] in the
context of the entire statute [citation] and the statutory scheme of which it is a part. ‘We
are required to give effect to statutes “according to the usual, ordinary import of the
language employed in framing them.” [Citations.]’ [Citations.] ‘ “If possible,
significance should be given to every word, phrase, sentence and part of an act in
pursuance of the legislative purpose.” [Citation.] . . . . “When used in a statute [words]
must be construed in context, keeping in mind the nature and obvious purpose of the
statute where they appear.” [Citations.] Moreover, the various parts of a statutory
enactment must be harmonized by considering the particular clause or section in the
context of the statutory framework as a whole. [Citations.]’ [Citations].” (Du Bois v.
Worker’s Comp. Appeals Bd. (1993) 5 Cal.4th 382, 387-388.)
In evaluating Zuniga’s due process claim, “we are mindful that ‘[a]ll presumptions
and intendments favor the validity of a statute and mere doubt does not afford sufficient
reason for a judicial declaration of invalidity. Statutes must be upheld unless their
unconstitutionality clearly, positively and unmistakably appears.’ (Lockheed Aircraft
Corp. v. Superior Court of Los Angeles County (1946) 28 Cal.2d 481, 484; see also
director’s informal opposition and in the amicus brief. In a focus letter, we asked the
parties to be prepared to address at oral argument how Stevens and Ramirez apply to this
case, which they did.
8
[Stevens, supra,] 241 Cal.App.4th [at p.] 1092.)” (Chorn v. Workers’ Comp. Appeals Bd.
(2016) 245 Cal.App.4th 1370, 1381.)
B. The Board Has No Authority to Order Disclosure of the Identity of
IMR Reviewers
We have no difficulty concluding that section 4610.6, subdivision (f), which says,
“The [IMR] organization shall keep the names of the reviewers confidential in all
communications with entities or individuals outside the [IMR] organization,” prohibits
the Board from ordering Maximus to disclose the identities of the individuals who
conducted the IMRs of Zuniga’s request for treatment. The language of the statute is
unambiguous. Zuniga cites no statute or case that suggests the Board has the authority to
order the IMR to perform an action that is specifically prohibited by statute. Nor does he
cite any statute or case that suggests this unambiguous confidentiality requirement is
abrogated by the reversal of an IMR decision that was based on an erroneous finding of
fact. To the contrary, when an IMR determination is reversed the only authorized action
is for the Board to remand the dispute to the administrative director to submit it for a new
IMR review. (§ 4610.6, subd. (i).)
The confidentiality requirement of section 4610.6, subdivision (f) is consistent
with the Legislature’s purpose in “establishing the IMR process to resolve workers’
challenges to adverse UR decisions. (Stats. 2012, ch. 363, § 1.)” (Stevens, supra, 241
Cal.App.4th at p. 1089.) The Legislature found that “[t]he existing process of appointing
qualified medical evaluators to examine patients and resolve treatment disputes [was]
costly and time-consuming, and it prolong[ed] disputes and cause[d] delays in medical
treatment for injured workers.” ([Stats. 2012, ch. 363,] § 1(f).) The IMR process was
intended to change the previously existing system in which “each side attempt[ed] to
obtain medical opinions favorable to its position, and then counsel for each side trie[d] to
convince a workers’ compensation judge based on this evidence what the proper
treatment is. This system of ‘dueling doctors’ with lawyer/judges making medical
decisions has resulted in an extremely slow, inefficient process that many argue does not
provide quality results.” (Sen. Com. on Labor and Industrial Relations, Analysis of Sen.
9
Bill No. 863 (2011-2012 Reg. Sess.) as amended Aug. 30, 2012, p. 6.) In the IMR
process, “a conflict-free medical expert would be evaluating medical issues and making
sound medical decisions, based on a hierarchy of evidence-based medicine standards
drawn from the health insurance IMR process, with workers’ compensation-specific
modifications.” (Id. pp. 6-7.) The Legislature found that “[t]imely and medically sound
determinations of disputes over appropriate medical treatment require the independent
and unbiased medical expertise of specialists.” (Stats. 2012, ch. 363, § 1(f).)
The Legislature’s understanding that confidentiality helps to ensure that IMR
reviewers are independent and unbiased is reflected in an analysis of a proposed, but not
adopted, change to the IMR process. Senate Bill No. 626 was introduced in 2013 to
reverse provisions of the 2012 workers’ compensation reform, which had included the
establishment of the IMR process. (Sen. Com. on Labor and Industrial Relations,
Analysis of Sen. Bill No. 626 (2013-2014 Reg. Sess.) as amended Apr. 18, 2013, p. 1.)
Among other things, the bill proposed removing the confidentiality requirement for IMR
reviewers. (Id. p. 3.) The bill analysis commented that, while the IMR process had been
in effect for only six months, it “promises to speed up medical treatment and increase
objectivity in the provision of medical services.” (Id. at p. 4.) The analysis further
commented that, while the full impact of removing the confidentiality requirement was
unknown, “one fear is that it would reduce the independence of the reviewer.” (Id. at pp.
3-4.)
We are not persuaded by Zuniga’s argument that the confidentiality requirement
conflicts with section 4610.6, subdivision (i), which provides that when an IMR
determination is reversed, the Board must remand the matter to another IMR
organization, or, if there is only one organization, as is the case here, to the original
organization for review by a different reviewer. Zuniga argues that the Board has
authority to enforce and modify its orders, as set forth in section 133, and therefore if it is
to enforce orders made under section 4610.6, subdivision (i), it must have the authority to
compel the disclosure of IMR reviewers’ identities. Zuniga argues that if the Board
could not compel disclosure of reviewers’ identities, “section 4610.6(i) would be
10
rendered meaningless because the remedy available to the Board would become
unenforceable.” As the administrative director’s informal opposition correctly points out,
questions about whether two IMRs were performed by different reviewers can be
addressed short of releasing the reviewers’ names, such as by providing additional
information about their backgrounds, or by requiring declarations under penalty of
perjury from an officer of the IMR organization or a reviewer. Zuniga points to no
authority to suggest that a statute is rendered meaningless simply because his preferred
method of enforcing it is unavailable.
Similarly, Zuniga asserts that the confidentiality requirement conflicts with
subdivisions (h)(1) through (h)(4) of section 4610.6, which set forth four of the five
grounds on which an appeal of an IMR determination may be taken: the director acted
without authority, the decision was procured by fraud, the physician reviewer had a
material conflict of interest, or the decision was the result of bias. Zuniga contends that
an injured employee cannot prove any of those grounds unless the employee and the
Board are aware of the identity of the reviewer, and that therefore the confidentiality
provision of section 4610.6, subdivision (f) renders meaningless these grounds for
appeal.9 We are not persuaded. For example, if an IMR decision were found to be based
on an incorrect interpretation of the relevant medical standards, the IMR could be
overturned on the grounds that the director acted without authority. (Stevens, supra, 241
Cal.App.4th at p. 1101.) Impermissible bias influencing a determination might be
reflected in the nature or text of the IMR determination.10 And although confidentiality
9
Zuniga implicitly concedes, as he must, that even without knowing the identity
of the IMR reviewer, an IMR determination can successfully be appealed on the ground
that it is based on a plainly erroneous finding of fact, the fifth listed ground for appealing
an IMR determination. (See § 4610.6, subd. (h)(5).)
10
For example, an IMR review may be subject to challenge for bias if it includes
language indicating that the determination is based on some generalization about race,
ethnic group, age, sex or disability, rather than on the “specific medical needs of the
employee and the standards of medical necessity.” (§ 4610.6, subd. (c).) Here, the IMRs
include no such language.
11
may make it more difficult to challenge an IMR determination on the basis of a conflict
of interest, “workers have the opportunity to obtain significant other information bearing
on conflicts of interest, including information about the IMR organization’s ‘method of
selecting expert reviewers and matching [them] to specific cases,’ system of identifying
and recruiting expert reviewers, and method of ‘ensur[ing] compliance with the
[statutory] conflict-of-interest requirements.’ (§ 139.5, subds. (d)(2)(F)-(H); see id. subd.
(e).)” (Stevens, supra, 241 Cal.App.4th at p. 1100, fn. 18; see also Ramirez, supra, 10
Cal.App.5th at p. 229.)
In sum, section 4610.6, subdivision (f) prevents the Board from ordering an IMR
to disclose the names of IMR reviewers, and we therefore reject Zuniga’s various
arguments as to why the Board can order an IMR organization to release names of
reviewers.11
C. Keeping Reviewers’ Identities Confidential Does Not Violate Due Process
Zuniga argues that if section 4610.6, subdivision (f) precludes the Board from
ordering the disclosure of the identity of IMR reviewers, then that statutory provision and
the entire IMR scheme violate the federal and state due process rights of injured workers.
He argues that “due process requires a party to a workers’ compensation claim [to] be
able to verify the qualifications of the person making the final determination as to
whether benefits are to be awarded in a particular case, but the law currently forbids such
11
Over the course of this litigation, Zuniga’s position on why the Board can order
the disclosure of reviewer names has changed. Initially, after the first IMR was reversed
but before the second was issued, Zuniga argued to the Board that the names should be
disclosed once an IMR is overturned so that if the second IMR is performed by the same
person the applicant can dispute it on that ground. After the second IMR was issued, he
argued that knowing the identities of the reviewers would open the possibility of cross-
examining them “to determine if there was cause for further appeal.” Permitting cross-
examination for the purpose of uncovering additional grounds to challenge an IMR
determination would undermine the Legislature’s intent in adopting the IMR provisions
to reduce litigation and its attendant costs and delays. (Stats. 2012, ch. 363, § 1(b); see
also Stevens, supra, 241 Cal.App.4th at p. 1091.)
12
an inquiry.”12 He argues that the IMR reports are testimonial in character and that
therefore due process requires he be allowed to cross-examine the doctors issuing the
reports, which he cannot do if the identities of IMR reviewers are confidential.13 We are
not persuaded.
To address Zuniga’s California due process claim, it is necessary to understand the
constitutional basis of the workers’ compensation law. Under Article XIV, Section 4 of
the California Constitution, the Legislature “is . . . expressly vested with plenary power
unlimited by any provision of this Constitution, to create, and enforce a complete system
of worker’s compensation by appropriate legislation.” (Cal. Const., art. XIV, § 4, italics
added.) As the Court of Appeal held in Stevens, the due process clause of the California
Constitution (Cal. Const., art. I, § 7, subd. (a)) does not limit the Legislature’s authority
to create a workers’ compensation system. (Stevens, supra, 241 Cal.App.4th at pp. 1092-
1093.) Section 4 therefore “supersedes the state Constitution’s due process clause with
respect to legislation passed under the Legislature’s plenary powers over the workers’
compensation system.” (Id. at p. 1093.)
Zuniga’s federal due process claim fails as well. The Court of Appeal in Stevens
concluded that the IMR process, including the confidentiality requirement of section
4610.6, subdivision (f), does not violate the federal due process clause. (Stevens, supra,
241 Cal.App.4th at pp. 1096-1101; see also Ramirez, supra, 10 Cal.App.5th at pp. 227-
12
Zuniga also argues that if the Board cannot order the disclosure of reviewers’
identities, the decisions are unreviewable, and therefore due process is violated. His own
experience in contesting an IMR determination shows that his premise is false: the first
IMR decision was reviewed and reversed without the identity of the reviewer being
revealed.
13
Zuniga also argues that the statutory scheme violates his right to due process
because in an IMR determination “an unknown and unknowable person with unknown
motives and biases makes a decision regarding the necessity of a particular medical
treatment, and no court or administrative tribunal may analyze or review that decision.”
Zuniga’s characterization of the IMR process is flatly incorrect. Under section 4610.6,
subdivision (h), IMR determinations are subject to review, and Zuniga sought, and
received, review of the IMR determination in his case.
13
229.) We agree with the reasoning in Stevens, which we summarize here. The Court of
Appeal in Stevens assumed that an IMR determination is state action and implicates a
protected property interest, which are prerequisites to a federal due process claim.
(Stevens, supra, 241 Cal.App.4th at pp. 1096-1098.) The court concluded that even so,
Stevens’s due process claim failed because the IMR process “afford[s] ample process.
‘The core of due process is the right to notice and a meaningful opportunity to be heard.’
(LaChance v. Erickson (1998) 522 U.S. 262, 266; see Cleveland Bd. of Educ. v.
Loudermill (1985) 470 U.S. 532, 547.) When due process must be afforded, the amount
of process required is determined by balancing the affected private interest, the risk of
erroneous deprivation of this interest, the probable value, if any, of additional or
substitute safeguards, and the government’s interest in the process. (Mathews v. Eldridge
(1976) 424 U.S. 319, 334-335.)” (Stevens, supra, 241 Cal.App.4th at p. 1098.)
In Stevens, the Court of Appeal was guided by California Consumer Health Care
Council, Inc. v. California Department of Managed Health Care (2008) 161 Cal.App.4th
684 (California Consumer), a case involving the denial of medical claims under the
Knox-Keene Act,14 where requests for medical care are reviewed under an IMR process
in which insurers are permitted to see and rebut claimants’ filings, but claimants are not
permitted to see and rebut insurers’ filings. (Stevens, supra, 241 Cal.App.4th at p. 1098.)
Despite that disparity, after balancing the interests in California Consumer, the Court of
Appeal upheld the Knox-Keene Act’s IMR process against a federal due process
challenge. (California Consumer, supra, 161 Cal.App.4th at p. 692.) In Stevens, the
Court of Appeal concluded that workers’ interest in obtaining medical services was
similar to that of the patients in California Consumer, but with multiple layers of review
the risk of erroneous deprivations under the worker’s compensation system was likely
less, and certainly not more, than under the Knox-Keene Act. (Stevens, supra, 241
Cal.App.4th at p. 1099.) And the court concluded that government’s interest in the IMR
14
The Knox-Keene Act is the Knox-Keene Health Care Service Plan Act of 1975,
Health and Safety Code section 1340 et seq., which regulates California health
maintenance organizations.
14
process, which was “expressly and comprehensively identified by the Legislature itself
when it established that process,” was at least as compelling as the government interest in
“not being forced to disclose insurance documents” in California Consumer. (Ibid.)
The court in Stevens specifically considered and rejected the argument that the
IMR process violates due process because the reviewers are not identified and cannot be
cross-examined. (Stevens, supra, 241 Cal.App.4th at pp. 1099-1100.) Contrary to
Zuniga’s assertion, IMR determinations are not testimonial in character. The court in
Stevens concluded that “[IMR] reviewers are not workers’ adversaries: they are
statutorily authorized decision makers. We have found no authority for the proposition
that a party has a right to cross-examine such decision makers.” (Stevens, supra, 241
Cal.App.4th at p. 1099.)15
As the Stevens court explained, “injured workers requesting treatment under the
workers’ compensation system are given detailed explanations of the reasons for a denial
or modification of their request, and they are given multiple opportunities to submit
evidence and challenge those decisions. ‘Procedural due process is not a static concept,
but a flexible one to be applied to the needs of the particular situation[s] . . . .’ ([Jennings
15
In claiming that IMR reports are testimonial in character, Zuniga relies on
Massachusetts Bonding & Ins. Co. v. Industrial Accident Commission (Himes) (1946) 74
Cal.App.2d 911, a case in which the Court of Appeal ruled that due process required a
workers’ compensation applicant to be able to cross-examine physicians whose reports
were submitted into evidence. The case is inapposite. Under the system at issue in
Himes, the commission made determinations on medical issues on the basis of evidence
that could include live testimony and physicians’ reports from petitioners and
respondents, which might well conflict, and it was well-established that due process
required that any reports filed after an open hearing be subject to cross-examination. (Id.
at pp. 913-914, 916.) Himes held that due process likewise required that testimony and
reports received as evidence during the hearing be subject to cross-examination. (Id. at
pp. 915-916.) Here, in contrast, the Board does not make determinations on medical
issues. “In no event shall a worker’s compensation administrative law judge, the appeals
board, or any higher court make a determination of medical necessity contrary to the
determination of the [IMR] organization.” (§ 4610.6, subd. (i).) IMR determinations can
be reversed only on non-medical grounds (§ 4610.6, subd. (h)), which have been
characterized as “nonsubstantive.” (Ramirez, supra, 10 Cal.App.5th at p. 213.)
15
v. Jones (1985)] 165 Cal.App.3d [1083], 1090-1091.) The IMR is only one aspect of the
process afforded to workers who request treatment, and we conclude that the process in
its entirety provides sufficient due process protections.” (Stevens, supra, 241
Cal.App.4th at pp. 1099-1100, fn. omitted; see also Ramirez, supra, 10 Cal.App.5th at p.
229.) These protections include the extensive conflict-of-interest and reporting
requirements imposed by statute on the IMR organization. (§ 139.5, subds. (c) through
(e).) For example, neither the IMR organization, nor its officers, directors or employees,
nor the experts it designates to conduct a review is permitted to have any material
affiliation, whether professional, financial, or familial, with the employer, insurer, claims
administrator, utilization review organization, employee, physician or other provider
involved in the treatment being disputed, or the facility where the services recommended
by any party would be provided. (§ 139.5, subd. (c)(2).) The IMR organization must
identify its major stockholders and major bond or note holders, provide information about
affiliated organizations (including the nature and extent of any ownership or control, and
that affiliated organization’s type of business) and revenue sources, and provide the
names and biographical information about the organization’s directors, officers and
executives, including their past or present relationships with such entities as workers’
compensation insurers and medical provider networks. (§ 139.5, subd. (d)(2).) Further,
the IMR organization must “demonstrate that it has a quality assurance mechanism in
place” that, among other things insures the independence of the medical experts
designated to make IMR determinations and adequate screen for conflicts of interest.
(§ 139.5, subd. (d)(3)(E).) And the Division must provide “upon the request of any
interested person, a copy of all nonproprietary information, as determined by the
administrative director, filed with it” by an IMR organization. (§ 139.5, subd. (e).)
Zuniga mischaracterizes the IMR process as one that provides for no review, and
does not even attempt to identify or balance the interests implicated in this case. We
conclude that Zuniga has not demonstrated that his due process rights are violated by the
statutory provision that the identity of IMR reviewers must remain confidential.
16
DISPOSITION
The Board’s orders are affirmed. The parties are to bear their own costs.
17
_________________________
Miller, J.
We concur:
_________________________
Kline, P.J.
_________________________
Stewart, J.
18
Filed 1/25/18
CERTIFIED FOR PUBLICATION
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA
FIRST APPELLATE DISTRICT
DIVISION TWO
SAUL ZUNIGA,
Petitioner,
A143290
v.
WORKERS’ COMPENSATION (WCAB No. ADJ2563341)
APPEALS BOARD, INTERACTIVE ORDER CERTIFYING OPINION
TRUCKING, INC., et al., FOR PUBLICATION
Respondents.
BY THE COURT:
The opinion in the above-entitled matter filed on January 12, 2018, was not
certified for publication in the Official Reports. For good cause and pursuant to
California Rules of Court, rule 8.1105, it now appears that the opinion should be
published in the Official Reports, and it is so ordered.
Dated: _______________________ ________________________________
Kline, P.J.
19
Court: Workers’ Compensation Appeals Board
WCAB Judge: Hon. Christopher Miller
Attorneys for Petitioner Jonathan J. Belaga
Lisa E.. Ivancich
Pegnim &Ivancich
Attorneys for Respondent Lisa A. Liebson
State Compensation Insurance Fund Mary A. Huckabaa
Cynthia J.. Woelke
Attorneys for Amicus Curiae Michael A. Marks
California Workers’ Compensation Law Offices of Allweiss & McMurtry
Institute in support of Respondent Travis E. Cochran
Lozano Smith
A143290, Zuniga v. Workers’ Compensation Appeals Board
20