CompFox AI Summary
The Appeals Board granted reconsideration, rescinding the original order that found the defendant's utilization review (UR) denial untimely and automatically authorized treatment. While the UR denial was indeed untimely due to failure to serve applicant's attorney, the Board found no evidence of willful suppression of the Request for Authorization (RFA). Therefore, the issue of medical necessity remains undecided, and the case is returned for further proceedings to develop the record on this crucial point.
Full Decision Text1 Pages
The Appeals Board granted reconsideration, rescinding the original order that found the defendant's utilization review (UR) denial untimely and automatically authorized treatment. While the UR denial was indeed untimely due to failure to serve applicant's attorney, the Board found no evidence of willful suppression of the Request for Authorization (RFA). Therefore, the issue of medical necessity remains undecided, and the case is returned for further proceedings to develop the record on this crucial point.
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