The Death of the “Patterson” Doctrine: How the Rodriguez Decision Returns Control to Utilization Review

For over a decade, claims examiners have struggled with a common frustration: the “forever” treatment trap. You accept a treatment plan—like home health care or maintenance therapy—and suddenly, under the Patterson doctrine, you feel locked in. Even if the medical guidelines change, or if you simply want to re-evaluate the need, you are told you cannot stop the care without proving the applicant’s condition has “changed.”

That era effectively ended in November 2025.

In the landmark published decision Illinois Midwest Insurance Agency LLC v. WCAB (Rodriguez), the Second District Court of Appeal has explicitly overturned the Patterson doctrine for post-2013 injuries. Here is the story of the case, how we got here, and what you need to do on your desk tomorrow.

The Backstory: The “Patterson” Problem

To understand Rodriguez, we have to remember Patterson v. The Oaks Farm (2014). In that case, the Appeals Board carved out an exception to the Utilization Review (UR) process. They ruled that if an employer had previously authorized a course of treatment, they couldn’t just deny a later request for the same treatment through UR. Instead, the employer had to show a “change in the employee’s condition” or facts to justify terminating the care.

Effectively, Patterson allowed applicants to bypass Independent Medical Review (IMR) and run straight to a Workers’ Compensation Judge (WCJ) to get their “ongoing” care reinstated.

The Facts: Illinois Midwest v. WCAB (Rodriguez)

Orlando Rodriguez was a mechanic who suffered a severe head and brain injury in November 2016.² Given the severity of the injury, his treating physician requested home health care services.³ The claims administrator authorized this care for approximately one year.

In September 2019, the physician submitted a new Request for Authorization (RFA) to continue the home health care.⁴ This time, the examiner sent it to Utilization Review. The UR physician denied the request based on clinical guidelines.

Instead of appealing that denial through IMR (the standard process), Rodriguez’s attorney requested an Expedited Hearing. They argued that under Patterson, the employer had no right to stop the home health care because Rodriguez’s condition hadn’t changed—he still had the brain injury, and the need was “ongoing.”

The Legal Battle

The WCJ and the WCAB sided with Rodriguez. Relying on Patterson, they ruled that because the care was “ongoing,” the UR denial was invalid. They ordered the insurance company to keep paying.

The employer appealed, arguing that the legislative reforms of 2013 (SB 863) were designed to take medical decisions away from judges and give them to doctors.

The Court of Appeal agreed. In a decisive opinion, the Court held that:

1. Statutes are Clear: For injuries on or after January 1, 2013, the exclusive remedy for medical disputes is IMR.
2. No “Ongoing” Loophole: There is no statutory exception for “ongoing” treatment. Whether it is the first request or the fiftieth, a dispute over medical necessity belongs in UR/IMR, not before a judge.
3. Patterson is Rejected: The Court stated that Patterson created an “extra-statutory” rule that contradicted the Legislature’s intent to control costs and streamline cases.

Practical Impact: What Does This Mean for the Claims Examiners Desk and those eternal RFAs?

The Rodriguez decision is a powerful tool for claims management. It restores the authority of the UR/IMR process and removes the “change of condition” burden from the examiner.

Here is how to apply this ruling to your daily practice:

1. 1. Re-evaluate “Maintenance” Claims

Do you have files where you are paying for home health care, endless chiropractic, or massage therapy simply because a prior examiner authorized it years ago? You are no longer stuck. When the next RFA comes in, you have the right to submit it to UR for a fresh review against current MTUS guidelines.

1. 1. You Don’t Need to Prove a “Change”

If UR denies the ongoing care, you do not need to prove the applicant got better. You only need a valid, timely UR denial based on medical necessity. The burden of proof is on the applicant to show the care is medically necessary via IMR.

1. 1. Object to “Patterson” Arguments

If an applicant attorney files for an Expedited Hearing citing Patterson to challenge a UR denial, you can now confidently object to WCAB jurisdiction. Cite Illinois Midwest v. WCAB (Rodriguez) and argue that the judge has no authority to decide the medical necessity of the treatment.

1. The Caveat: Timeliness Matters

This decision saves you only if your UR is timely. If your UR is late, the Dubon rule still applies, and a judge can take jurisdiction. Tighten up your UR referral workflows to ensure you don’t lose this advantage on a technicality.

The Bottom Line

Rodriguez confirms that medical decisions should be made by medical professionals, not judges. It allows you to manage medical treatment based on current clinical evidence rather than past administrative decisions. Review your long-term medical files—it may be time to send those “ongoing” RFAs back to UR.

UPDATE: On 1/21/26, the Supreme Court granted a Petition for Review in Illinois Midwest Insurance Agency v. WCAB (Rodriguez) and case number S294463 has been assigned to this matter. A stay in the law did not issue and “…[p]ending review, the opinion of the Court of Appeal, which is currently published at 115 Cal.App.5th 1168, may be cited, not only for its persuasive value, but also for the limited purpose of establishing the existence of a conflict in authority that would in turn allow trial courts to exercise discretion under Auto Equity Sales, Inc. v. Superior Court (1962) 57 Cal.2d 450, 456, to choose between sides of any such conflict.