Aurigue, Cesar

Applicant Cesar Aurigue, a ramp agent who sustained industrial injuries to his left ankle, low back, right shoulder, and left hip on August 19, 2019, sought reconsideration of a WCJ finding that defendant's UR decision denying an RFA for a CARF-accredited functional restoration program was timely. The Board granted reconsideration, holding that defendant's March 26, 2025 request for additional information was timely under the five-business-day deadline, but defendant failed to issue a conditional denial within the mandatory 14 days of the RFA. Because the UR decision (issued April 7, 2025) was more than 14 days after the March 20, 2025 RFA transmission, it was untimely, conferring jurisdiction on the Board to determine medical necessity. The Board rescinded the original Findings, substituted a new Finding that UR was untimely, deferred the issue of reasonableness and necessity, and returned the matter to the WCJ for further proceedings.