Utilization review — the 2026 rules, and invalid denials

The April 1, 2026 restructure is confirmed from the regulation text itself. The law carries the note “Amendment of section heading, section and Note filed 12-30-2025; operative 4-1-2026 (Register 2026, No. 1)”, and the law carries “New section filed 12-30-2025; operative 4-1-2026.”

The Office of Administrative Law approved the package on December 30, 2025, and the DWCDWC Division of Workers’ Compensation, part of the Department of Industrial Relations. Administers the system. Information Services Center: 1-800-736-7401. describes it as implementing the SB 1160 exemption for treatment in the first 30 days and the AB 1124 formulary provisions, enforcing the UR accreditation requirement, and amending the UR investigation rules.

THE HARD FIVE-DAY FORMULARY CLOCK, CONFIRMED VERBATIM — § 9792.9.8(b)(3)

“The extension of time as set forth in section 9792.9.6 is not applicable to a request for authorization of a drug covered under this subdivision.”

On April 1, 2026, the utilization review regulations were restructured completely. The old single mega-regulation, 8 CCR § 9792.9.1, was broken into eight separate sections. The rulemaking was approved by the Office of Administrative Law on December 30, 2025.

This matters practically. An adjusterClaims administrator / adjuster The person handling your claim for the insurer or self-insured employer.’s form letter can still cite a regulation number that no longer contains what the letter says it contains.

A second, older error is even more common: the rule that only a physician may deny treatment is frequently cited to Labor Code § 4610(e). SB 1160 rewrote and re-lettered § 4610 effective January 1, 2018. The rule now lives at § 4610(g)(3)(A). Subdivision (e) today concerns a physician’s failure to file a § 6409 report — something else entirely. If your denial letter cites the old sections, that alone does not invalidate it. But it tells you something about how carefully the file is being handled.

Four steps

1. Your doctor files an RFA A Request for Authorization, DWC Form RFA, goes to the claims administrator. Under the new § 9785(h), secondary treating physicians may now file RFAs — a meaningful change for workers seeing specialists.
2. The clock starts The first day of counting is the first normal business day after receipt of a complete RFA — except where the timeline is measured in hours, which is counted from receipt.
3. A reviewer decides Approvals may be issued by non-physicians. Only a licensed physician may modify, delay, or deny, and the reviewer must be competent to evaluate the specific issue. Your treating physician is entitled to reach a peer by telephone during California business hours — the law requires the employer or insurer to maintain that access. It is an access duty on them, not a duty on the reviewer to call before denying.
4. You are notified And then the appeal clock starts.

How long a denial binds you. A decision to modify or deny stays effective as to the same treatment by the same physician — or another physician in the same practice group — for 12 months, unless there is a documented change in the facts material to the basis of the decision. That last clause is the whole game on a re-request. A new RFA that restates the same clinical picture will be denied again on the twelve-month rule. A new RFA documenting a genuine change — failed conservative care, new imaging, new objective findings — is a new request. In Medina v. Ajob Staffing (WCABWCAB Workers’ Compensation Appeals Board. The court system that decides these cases. 23 district offices statewide. panel, April 6, 2026), a physician’s report was held insufficient because it “merely restated prior opinions without identifying new diagnostic evidence or clinical changes.”

Five changes matter to injured workers. First: some treatment in the first 30 days no longer needs prior authorization. Labor Code § 4610(b) has been on the books since 2018 but was never implemented by regulation. New 8 CCR § 9792.9.7 is the operating rulebook. For dates of injury on or after January 1, 2018, treatment rendered within 30 days of the initial date of injuryDate of injury For a cumulative or occupational disease claim, the law sets it as when you first suffered disability and knew or should have known it was work-related — not when the wear began. Almost every deadline runs off this. is authorized without prospective UR — if all five conditions are met.

Back to change 1: the 30-day exemption applies only when every one of these holds.

• The body part or condition has been accepted as compensable — A disputed body part is outside the exemption.
• The treatment is consistent with the MTUS — The guideline still governs what qualifies.
• The treating physician timely submits DIR Form 5021 — The Doctor’s First Report, setting out the anticipated treatment plan.
• All anticipated treatment for those 30 days is set out in an RFA — Including exempt drugs.
• Bills are submitted within 30 days of service — 180 days for emergency treatment. And the Form 5021 and the complete RFA must both be submitted within five days of your first visit.

The clock runs from the initial date of injury — not the claim filing date, not the first medical visit, not the acceptance date. For cumulative traumaCT — Cumulative trauma Injury from repeated exposure over time. The largest injury category in California and the least claimed., the date of injury governs.

This is the part that decides cases. Under Dubon II (WCAB en banc, 2014), a UR decision that is untimely is invalid, and the medical necessity dispute goes to a workers’ compensation judgeWCJ Workers’ Compensation Judge. Decides your case. There is no jury. rather than to IMR. Stevens v. WCAB (2015) 241 Cal.App.4th 1074 upheld the constitutionality of IMR generally but left timeliness intact as a question the Board decides. Timeliness is now essentially the whole ballgame — and it is a genuinely winnable one.

GIRON v. KDF FORESTRY (WCAB PANEL, APRIL 6, 2026) — THE CASE TO KNOW

The RFA was received September 4, 2025. The decision was due September 11 — five business days. The employer made telephone calls to the treating physician and treated the request as extended to fourteen days. The panel reversed the trial judge and held the UR untimely: phone calls “did not automatically extend the deadline to 14 days under current law,” and the employer failed to provide the written notice of missing information required by § 4610(j)(2). With UR invalid, the Board decides medical necessity.

Only the timing items, the first three, make a decision invalid and send the dispute to a judge. The others are defects to raise in IMR.

• Was the decision made within 5 business days of a complete RFA? — That is the prospective and concurrent deadline.
• If an extension was taken, was written notice given within 5 business days — or was it handled by phone? — Giron says phone calls do not extend the deadline.
• Was the decision communicated to your doctor within 24 hours, and to you within 2 business days?.
• Was the denial signed by a physician? — A non-physician may approve; only a physician may deny.
• Was the reviewer competent in the relevant specialty? — The statute requires competence to evaluate the specific issue.
• Was telephone access to a peer reviewer actually available to your doctor during business hours? — § 4610(n) — note this is an access obligation, so its absence is evidence of a defective process rather than an automatic defect in the decision.
• Was the IMR application form and addressed envelope enclosed? — If not, your appeal clock never started.
• On a non-exempt formulary drug, was an extension asserted at all? — It is not available.

One argument worth preserving. The 14-day outer limit runs from two different events depending on which text you read. The law says “in no event more than 14 days from the date of the medical treatment recommendation by the physician.” The regulation, 8 CCR § 9792.9.6(c)(1), says fourteen days “from receipt of the completed or accepted request.” The physician’s recommendation almost always predates receipt. Where an RFA sat in a mailroom or clearinghouse, the statutory reading can make a decision untimely that the regulation would call timely. Preserve it.

Treatment is measured against the Medical Treatment Utilization Schedule, which incorporates ACOEM and other evidence-based guidelines and carries a presumption of correctness.

The presumption is rebuttable — by a preponderance of scientific medical evidence establishing that a variance is reasonably required. In practice, rebutting means the treating physician must cite the guideline, explain specifically why this patient falls outside it, and support the variance with evidence. An RFA that simply asserts the treatment is necessary will lose to the guideline every time.

The MTUS is updated on a rolling basis. The January 2026 ACOEM Ankle & Foot and Hip & Groin guidelines were adopted effective August 1, 2026.

Expedited UR — a 72-hour decision — applies where the standard timeframe would be detrimental to your life or health, or would jeopardize your ability to regain maximum function.

THE NUMBER WORTH SITTING WITH

In 2025, of 152,351 IMR determinations issued statewide, 108 were expedited. That is 0.07%.

Expedited review exists. It is almost never used. If your situation genuinely qualifies, it has to be requested and documented as such, in writing, by your physician — it will not happen on its own.

• Find the envelope and the service date — Everything runs from service, not receipt.
• Check whether the IMR form and addressed envelope were enclosed — If not, the clock has not started.
• Determine whether it is a drug-only dispute — If yes, you have 10 days, not 30.
• File the IMR application — Do not wait for anyone to do it for you.
• Send the denial letter to your treating physician — And ask two things: whether the clinical picture has materially changed, and whether the request should be resubmitted with MTUS citation and a documented rebuttal.
• Get the letter reviewed for timeliness — This is the single highest-value thing a lawyer does at this stage, and it takes minutes.
• Keep treating if you safely can — Denial of authorization is not a medical instruction.