Workers’ Compensation · Primary-source case analysis

Simmons: Utilization Review Does Not Decide Industrial Causation

By Aneeta Mishra and Timothy Chan

Published May 1, 2026

Simmons separates two questions that can become blurred in a treatment dispute: whether proposed care is medically necessary and whether the industrial injury caused the need for it.

The surgery was found medically necessary

The utilization-review physician agreed that proposed shoulder surgery was medically necessary but questioned whether the work injury caused the condition requiring surgery.

Utilization review has a limited function

The WCAB held that the utilization-review report was admissible to show that review occurred, that the treatment was medically necessary, and that an industrial-causation dispute had arisen. It was not admissible to prove or disprove industrial causation.

A causation dispute follows section 4062

Once medical necessity was accepted and causation remained contested, the parties had to use the agreed-medical-evaluator or qualified-medical-evaluator procedures then prescribed by section 4062.

Disposition

The Board rescinded the treatment award and returned the matter for development of admissible medical evidence on causation. The decision did not allow a utilization-review doctor to resolve that issue.

Key takeaways

• Separate medical necessity from industrial causation.
• Use utilization review only for its statutory purpose.
• Invoke the proper medical-evaluation procedure when causation is disputed.
• Build the evidentiary record before seeking a treatment award.