Jose Dubon

In this en banc decision, SCIF petitioned for reconsideration of the Appeals Board's February 27, 2014 en banc decision (Dubon I), which had held that the WCAB has jurisdiction to determine whether a utilization review (UR) decision is timely and procedurally valid, and that a UR decision found invalid is not subject to IMR but is decided by the WCAB on medical necessity. SCIF argued that 'any dispute' over a UR decision, including timeliness and procedural validity, must be resolved through IMR under Labor Code section 4610.5 and SB 863, and that even if the WCAB has authority over those issues, it should not determine medical necessity itself. Because of statutory time constraints and the need to further study the factual and legal issues, the Board granted reconsideration to allow opportunity to issue a just and reasoned decision. The February 27, 2014 en banc Dubon opinion was ordered to remain in effect and binding pending the Decision After Reconsideration. The Board also ordered all further pleadings to be filed only with the Office of the Commissioners in San Francisco.