Lopez Franco, Jose

Applicant Jose Lopez Franco, a mason who fell into a 15-foot trench in 2019 sustaining injuries to his rib, spine, and pelvis (and claimed head injury), sought reconsideration of a WCJ finding that a November 27, 2024 RFA marked for expedited review did not qualify for expedited treatment and that defendant's December 11, 2024 UR decision was timely, depriving the WCAB of jurisdiction. The treating physician submitted the RFA requesting expedited review for a supported living program, but defendant's UR provider (Genex) did not respond within 72 hours, instead issuing an unsigned letter on December 3, 2024 declaring the request unsupported and converting it to standard review. The WCAB majority granted reconsideration, holding that whether an RFA establishes the need for expedited review is an inherently medical determination that must be made and communicated by a medical professional within the 72-hour expedited timeframe. Because no medical professional timely evaluated the RFA's urgency, the December 11, 2024 UR decision was untimely, vesting the WCAB with jurisdiction over the medical treatment dispute. The Board rescinded the F&O, substituted findings that the UR was untimely, and remanded to the WCJ to determine medical necessity. Commissioner Razo dissented, finding no statutory requirement to communicate the expedited determination within 72 hours and approving use of non-physician reviewers for processing.