Bautista, Sheila

Applicant Sheila Bautista, who suffered a traumatic brain injury and post-concussion syndrome, sought reconsideration of a WCJ's F&O finding that defendant's March 26, 2025 UR determination by Genex was timely. Dr. Prasad had submitted an RFA on March 20, 2025 marked for expedited review, requesting a day treatment program and medication refills, certifying that the applicant faced an imminent and serious threat to her health. Defendant routed the RFA to Genex only on March 25, 2025, after the 72-hour expedited timeframe had already lapsed, and the determination unilaterally downgraded the request to non-expedited review without any medical professional evaluating whether expedited review was warranted. The Board granted reconsideration, holding that the determination of whether an RFA establishes the need for expedited review is itself a medical question that must be made and communicated by a medical professional within 72 hours. Because no medical professional reviewed the urgency within the required timeframe, the UR was untimely, vesting the WCAB with jurisdiction over the medical treatment dispute under Dubon. The matter was remanded to the WCJ to determine medical necessity.