Jose Martinez Gonzalez — ADJ10946749

Defendants Hospitality Staffing Solutions and Chubb Indemnity Insurance (administered by ESIS) sought reconsideration of a WCJ's Findings and Order awarding lien claimant Dental Trauma Center $15,883.59 plus a 15% increase and 10% annual interest. The central dispute was whether defendants could conduct retrospective utilization review based on their denial of the claim without first issuing a written deferral decision complying with AD Rule 9792.9(b)(1) within five business days of receiving the RFA. The Board affirmed the WCJ, holding that a claims administrator wishing to defer UR must send a compliant written deferral notice, and that the permissive 'may' in the regulation only means the administrator may not defer except as prescribed. The Board also upheld findings that the sole dental expert (Dr. Schames) constituted substantial medical evidence on causation and medical necessity, that inconsistent reports of non-dental providers did not rebut him, and that the billing amount based on the unrebutted Kunz study and expert testimony was reasonable. The petition was denied and the Findings and Order affirmed.