Injured workers in California are entitled to “reasonable medical treatment” to cure or relieve the effects of their work-related injury. But here’s the catch: every step of your care has to be approved — and that process starts with something called a Request for Authorization, or RFA.
A properly prepared RFA can mean the difference between getting essential medical care quickly — or facing delays, denials, and unnecessary pain. At Employees First Labor Law, we help ensure our clients’ RFAs are not only submitted but strategically drafted to survive Utilization Review (UR) and maximize case value.
This guide explains how RFAs work, why they get denied, and how to prepare persuasive ones that get results.
What Is an RFA?
A Request for Authorization (RFA) is a form submitted by your Primary Treating Physician (PTP) or another authorized provider requesting approval from the insurance company to:
- Provide specific treatment
- Order diagnostic tests (e.g., MRI, CT scan)
- Refer to a specialist (e.g., pain management, orthopedic surgeon, psychiatrist)
- Prescribe medication
- Request durable medical equipment (e.g., brace, wheelchair)
- Approve therapy or procedures (e.g., physical therapy, epidural injections)
The RFA triggers Utilization Review (UR) — a process where the insurance company decides if the requested treatment is medically necessary under the Medical Treatment Utilization Schedule (MTUS).
Why Are RFAs So Important?
RFAs don’t just affect your treatment — they impact the entire value and trajectory of your case:
- Approval can lead to better medical outcomes and higher Permanent Disability ratings
- Denial can lead to worsened conditions and a lower settlement
- Delays in care may justify penalties or sanctions against the insurance company
- Well-supported RFAs create a strong evidentiary record in your favor
- Multiple denials may allow you to challenge the carrier’s good-faith compliance
Common Reasons RFAs Are Denied
Most denials aren’t based on malice — they’re based on technical failures or lack of detail. Common issues include:
- Vague treatment descriptions (e.g., “therapy” instead of “12 sessions of PT, 2x/week for 6 weeks”)
- No reference to MTUS or ACOEM Guidelines
- Missing supporting documents like chart notes or prior test results
- Lack of functional impact (i.e., how the condition affects work or daily life)
- Duplicate or outdated RFAs
- Wrong form or incomplete sections
At EFLL, we regularly review denied RFAs and find they could have been approved with just a few strategic improvements.
How to Prepare a Persuasive RFA
Here’s what you — and your treating physician — should focus on when preparing an RFA that sticks.
1. Be Specific and Quantifiable
Avoid vague language like “refer to ortho” or “start therapy.” Instead, say:
“Refer to Dr. Smith, board-certified orthopedic surgeon, for evaluation of left knee injury with possible surgical recommendation due to failed conservative treatment.”
OR:
“Requesting 12 sessions of physical therapy, 2x/week for 6 weeks, per MTUS guidelines for moderate lumbar strain.”
2. Reference the MTUS or Medical Guidelines
UR reviewers base decisions on the Medical Treatment Utilization Schedule (MTUS) or ACOEM guidelines.
Your doctor should include:
“Per MTUS (Low Back Disorders, 2023), active therapy is appropriate for subacute lumbar strain where passive treatment has failed.”
This shows that the treatment isn’t arbitrary — it’s supported by state-sanctioned medical evidence.
3. Include Detailed Chart Notes and Justification
Always attach:
- Relevant chart notes
- Objective findings (e.g., imaging, range of motion deficits)
- Prior treatments and outcomes
- Functional limitations (e.g., unable to sit >30 mins, can’t lift >10 lbs)
“Patient failed 6 weeks of conservative care including NSAIDs and home exercise. Still unable to ambulate without pain. MRI shows disc herniation at L4-L5. Recommending epidural steroid injection.”
4. Demonstrate Impact on Work or ADLs
The more your doctor ties the injury to real-world consequences, the better. Include how the condition affects:
- Ability to perform job duties
- Activities of daily living (ADLs)
- Pain levels and sleep
- Emotional or psychiatric stability
“Injury limits ability to drive, climb stairs, and stand >15 minutes. Causing sleep disruption and depression symptoms. Interferes with job duties as warehouse supervisor.”
5. Coordinate Timing Strategically
Submit RFAs:
- After clear documentation of failed prior treatment
- After new diagnostic testing supports the need
- Just before an important hearing or milestone in the case
- As part of a package with P&S report or QME rebuttal
This prevents insurers from saying “too early” or “no new evidence.”
What Happens After the RFA Is Submitted?
Under Labor Code § 4610, the insurance company must respond to the RFA within:
- 5 business days for standard RFAs
- 72 hours for urgent or expedited RFAs
If they deny or modify the request, they must issue a written decision — which you can challenge through:
- Independent Medical Review (IMR)
- Expedited hearing before a Workers’ Comp Judge
- Penalties for delays or bad-faith denials
EFLL regularly files DORs and penalty petitions when insurers abuse the UR process.
How EFLL Helps Maximize Treatment and Case Value
Our attorneys don’t just litigate — we coordinate with medical providers to:
- Ensure treatment is documented with disability and impairment evidence
- Use denied RFAs to support future medical or C&R settlements
- Push for care that improves recovery and raises PD ratings
- File penalties when carriers unreasonably delay or obstruct care
Don’t Let a Weak RFA Derail Your Care — or Your Case
Insurance companies deny treatment when RFAs are sloppy, vague, or unsupported. But with the right preparation, strategy, and legal backup, you can get the care you need — and the compensation you deserve.
Call Employees First Labor Law today for a free consultation.
✅ We’ll review your treatment history
✅ Help build stronger RFAs with your doctors
✅ Fight for your full range of benefits and future medical
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