CompFox AI Summary
This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in Dubon II, the Appeals Board reversed this finding. The Board ruled that under Dubon II, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.
Full Decision Text1 Pages
This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in Dubon II, the Appeals Board reversed this finding. The Board ruled that under Dubon II, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.
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