Understanding the Utilization Review Process: How to Get Proper Treatment from a Workers’ Comp Doctor

When your injury is serious, the difference between full recovery and lifelong limitation often depends on whether you get the right kind of worker’s comp doctor. Serious injuries in the workplace require a specialized medical care provider who understands complex work injuries.

Unfortunately, many California workers suffering from work-related injuries find themselves stuck in a frustrating loop: refused MRIs, delayed surgery approvals, and “recommendations” to see general doctors, who often can’t truly evaluate or treat their condition. 

Behind these denials lies a bureaucratic process called Utilization Review (UR). Utilization Review is a system meant to ensure appropriate care, but can be used as a cost-cutting tool against injured California workers. Our workers’ comp attorneys know the UR process well, and fight for the rights of California workers.

The Importance of Finding the Right Workers’ Comp Doctor

Most workers’ compensation primary treating physicians are general practitioners. They’re allowed to see injured workers, prescribe medication, and recommend treatment. But when an injury goes beyond a sprain or strain, their scope is limited. They often lack the advanced training or surgical background needed to diagnose damage properly.

Consider a torn rotator cuff, herniated disc, or complex knee reconstruction case. These injuries require a workers’ comp doctor in Southern California who specializes in industrial injuries—not a generalist whose most powerful diagnostic tool might be X-rays.

What Is The Utilization Review Process?

The utilization review process is a mandatory evaluation used by insurers to determine whether or not an injured worker’s requested medical treatment is necessary, appropriate, and aligned with evidence-based guidelines. Even when your treating doctor correctly recommends specialist care, the request must pass through Utilization Review. 

This allows insurance carriers the opportunity to routinely cut or delay medical authorizations. Many injured workers are shocked when a UR doctor, who has never met them, denies an MRI or surgery request because they deem it “not medically necessary.”

These decisions often inflict real damage. Every week, we talk to workers whose recovery has stalled because a UR doctor decided they could just “keep trying therapy” for another 6 to 12 weeks before surgical review. Meanwhile, your condition worsens, and your chance for full recovery shrinks. 

At SoCal Workers Comp, we’ve seen how damaging these delays can be to our clients’ bodies, confidence, and families. California workers work hard for their employers, and deserve much more than a single evaluation designed to benefit the insurer rather than accommodating the worker.

How to Get Treatment When Denied Care By Utilization Review 

When a critical treatment, MRI, or surgery is denied by Utilization Review, you have legal rights to appeal the decision. The process is complicated and insurance carriers often bank on workers not knowing how to fight back. At SoCal Workers Comp, we want you to have the tools necessary to get the treatment you need.

Here’s how the system is supposed to work:

• Step 1: Your primary doctor submits a Request for Authorization (RFA).
• Step 2: The insurance company sends the request to Utilization Review to make a determination within five business days but no later than 14 days.
• Step 3: If denied, the decision can be challenged through Independent Medical Review (IMR).

In practice, timing deadlines of the Utilization Review get missed, paperwork disappears, and medical language becomes a weapon. That’s where having a dedicated workers’ compensation attorney from SoCal Workers Comp can make a world of difference.

Related Article: Workers Comp Insurance Adjusters and Insurance Steering: The Importance of Calling a Lawyer

How A Workers Comp Attorney Can Help in the Utilization Review Process

Our workers comp attorneys aggressively monitor every RFA submission and UR decision on your behalf. If your recommended surgery is denied, we take immediate steps to preserve appeal rights, challenge invalid UR timelines, and refer you to top workers’ comp doctors in Southern California for second opinions.

We also look for leverage points, such as instances where UR denials present opportunities to seek clarification from your doctors and we work to get that information. Our goal is simple: to make sure you’re not left waiting, deteriorating, or being told to “just manage” pain that requires legitimate intervention.

Related Article: How to Legally Switch Doctors Under California Law

What to Expect When Partnering with Workers Comp Attorneys

Our workers comp attorneys at SoCal Workers Comp see cases through from start to finish. We are a workers-first firm that prioritizes the health and well-being of our clients. Our mission isn’t just to win benefits; it’s to get you the specialized medical care you actually need to truly recover from your workplace injury.

We fight for cases struggling through the system, and we don’t accept delays, dismissive UR reports, or “cookie-cutter” doctors as the final word on your health.

Here’s what our firm does differently:

• We match you with real specialists. Whether you need an orthopedic surgeon, neurologist, or pain management expert in California, we have the professional network and experience to coordinate legitimate specialists who understand how to document and defend their care recommendations.
• We handle UR appeals strategically. Every denial becomes an opportunity to expose flaws in the process. We analyze medical rationale, track compliance with the California Labor Code, and escalate invalid denials to the Independent Medical Review or the Workers’ Compensation Appeals Board when necessary.
• We protect your rights from day one. The insurance adjuster and nurse case manager exist to minimize costs—not maximize recovery. Our job is to make sure your claim moves forward legally, medically, and humanly.
• We communicate what’s happening at every step. No legal jargon, no silence during delays. We keep you informed about your treatment requests, appeal timelines, and court actions so you always know how your care is being defended.

When a serious injury threatens not only your health but also your livelihood and self-worth, you need a law firm that refuses to let the system bury your claim in “UR red tape.” That’s the philosophy behind SoCal Workers Comp: we believe hard work should earn you a secure recovery, not a permanent struggle caused by denied medical care.

Related Article: Putting the Injured Worker First: Robert Rettenmaier and Yawar Chaudhry to Attend the California Applicants' Attorneys Association 2026 Winter Convention

Taking the Next Step Toward Real Recovery

If you’ve been denied a surgery, MRI, or specialist referral through Utilization Review, don’t wait for the system to fix itself. The longer you’re forced to delay treatment, the harder recovery becomes—and the more insurers benefit from your frustration.

Whether you’re dealing with a denied orthopedic surgery, need a second opinion from a top orthopedic surgeon in California, or simply want clarity about your rights after a UR denial, we’re ready to help.

At SoCal Workers Comp, we fight for injured workers every day. We know how to turn denials into approvals, delays into action, and paperwork into progress.

Call us today or submit our online consultation form for a free case review. You’ve worked hard enough… Now it’s time for someone else to fight for your recovery.