Robert Flores — ADJ7864220

Applicant Robert Flores, who sustained an industrial left knee injury in 2011 while employed as a coach, sought reconsideration of an April 11, 2022 F&O that upheld a November 30, 2020 IMR determination denying an ultrasound-guided PRP injection to his left knee. The MTUS offered no affirmative recommendation for PRP injections for knee osteoarthritis, so UR applied the ODG (as authorized when a condition is not addressed by the MTUS) to non-certify the treatment, while IMR upheld that denial by applying general MTUS standards requiring documentation of objective functional goals. Applicant argued that the 2016/2017 amendment to section 4610.5(c)(2) removed the medical evidence hierarchy, requiring IMR to consider all listed standards without ranking. The Board rejected this, finding the UR/IMR process properly applied MTUS and ODG standards as required by section 4610.5(c)(2) and AD Rule 9792.21.1, and that applicant failed to establish by clear and convincing evidence that the IMR determination was based on a plainly erroneous fact of ordinary knowledge rather than expert opinion. The Board affirmed the F&O.