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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. ADJ6989761
Regular
Sep 30, 2013

ELVIN SALGUERO vs. CHARLES GEMEINER CABINETS, INSURANCE COMPANY OF THE WEST

This case involves an applicant seeking reconsideration of a denial for 24/7 home care. The applicant argues the denial was an abuse of discretion, as medical evidence supported the need for such care due to suicidal ideation and depression. The Workers' Compensation Appeals Board denied the petition, adopting the judge's report which found no support for 24/7 home care in relevant treatment guidelines. The judge concluded that the applicant failed to prove the requested care was reasonable and necessary beyond the requirements of existing guidelines.

WCABPetition for ReconsiderationHand Surgery EvaluationStellate Block ProceduresHome CarePsychiatric TechnicianLicensed Vocational NurseSuicidal IdeationPsychiatric HospitalizationLabor Code Section 4600(b)
References
Case No. SAC 286368
Regular
Jan 25, 2008

DALE OLIVER vs. BRIAN WILLIAMS CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking approval for disc replacement surgery for a work-related back injury. The defendant argued the surgery is experimental per ACOEM guidelines, thus not covered. The Board denied reconsideration, finding the applicant's physician rebutted the presumption of experimental status. The Board determined the surgery is no longer experimental, citing FDA approval, and is reasonably required for the applicant's specific condition, supported by expert medical opinion.

Workers' Compensation Appeals BoardBrian Williams ConstructionState Compensation Insurance Fundindustrial injuryright anklefootelbowshoulderskneesleft lower extremity
References
Case No. ADJ15329380
Regular
Oct 31, 2025

BERTHA VALERIO vs. KIMCO STAFFING SERVICES, INC.; XL INSURANCE

Defendant sought reconsideration of a Findings and Award (F&A) from August 5, 2025, concerning an injury sustained by applicant Bertha Valerio on September 9, 2021. The F&A found that applicant's injury was AOE/COE, defendant failed to prove improper treatment outside the Medical Provider Network (MPN), and lien claimant Joyce Altman Interpreting, Inc. established their market rate for interpreting services. Defendant contended that medical treatment and interpreter services were unreasonable due to treatment outside the MPN and failure to adhere to MTUS/ACOEM guidelines, and that the market rate for interpreter services was not properly established. The Appeals Board denied the petition, agreeing with the WCJ that defendant failed to sustain its burden of proof on the MPN issue, the MTUS/ACOEM guideline issue was not raised at trial, and lien claimant properly established their market rate.

WCABPetition for ReconsiderationFindings and AwardMedical Provider NetworkMPNRequests for AuthorizationRFAsLien ClaimantMarket RateLabor Code Section 4600
References
Case No. ADJ900432 (SAC 0323091)
Regular
Dec 30, 2011

MARLENE COPUS vs. NORTH SACRAMENTO ELEMENTARY SCHOOL DISTRICT

This case involves a dispute over the necessity of spinal surgery for an applicant who sustained a cumulative trauma injury to her neck and back. While the applicant's treating physician recommended surgery, a second opinion physician disagreed, citing a lack of nerve root compression. The Appeals Board found that the medical evidence was insufficient to determine the necessity of surgery, particularly in light of ACOEM Practice Guidelines which generally recommend against surgery without nerve root compression. Therefore, the Board rescinded the prior award and remanded the case to appoint an independent physician to evaluate the applicant and determine the reasonableness and necessity of the proposed surgery.

Workers' Compensation Appeals BoardMarlene CopusNorth Sacramento Elementary School Districtcumulative traumaspinal surgerynerve root impingementcervical stenosisDr. OrisekDr. GregoriusACOEM Practice Guidelines
References
Case No. ADJ4028210 (SJO 0251585)
Regular
Apr 06, 2009

JENNY PHAM vs. SANMINA-SCI CORPORATION, SENTRY CLAIMS SERVICE

This case concerns a dispute over the reasonableness and necessity of chiropractic and acupuncture treatment provided to an applicant for an industrial injury. The defendant argues the treatment exceeded the ACOEM Guidelines and was not evidence-based. The Appeals Board granted reconsideration, finding the WCJ's prior decision allowing the lien premature. The Board rescinded the decision and returned the case for further development of the medical record to determine if the treatment complied with the ACOEM Guidelines. The defendant's petition for removal was dismissed as moot.

Petition for RemovalPetition for ReconsiderationFindings and OrderCompromise and ReleaseIndustrial InjuryNeck InjuryBilateral ShouldersReasonable and Necessary TreatmentACOEM GuidelinesLabor Code Section 4600
References
Case No. STK 0209780 STK 0209781
Regular
Feb 08, 2008

TAMARA JEAN STAFFORD vs. LODI UNIFIED SCHOOL DISTRICT, ALTERNATIVE SERVICE CONCEPTS

The Workers' Compensation Appeals Board denied the Lodi Unified School District's petition for reconsideration, affirming the administrative law judge's award of pain medications and trigger-point injections to applicant Tamara Jean Stafford. The Board found the defendant's utilization review physician improperly applied ACOEM guidelines, which primarily address acute injuries, to the applicant's chronic condition. The Board clarified that while ACOEM guidelines are presumptively correct, variances are permissible when reasonably required to cure and relieve an employee's injury effects, as demonstrated by the applicant's treating physician's recommendations.

Workers' Compensation Appeals BoardLodi Unified School DistrictAlternative Service ConceptsTamara Jean StaffordPetition for ReconsiderationFindings and AwardMedical TreatmentPrimary Treating PhysicianACOEM GuidelinesUtilization Review
References
Case No. ADJ8115084
Regular
Jun 02, 2014

MARY HAYWORTH vs. KCI HOLDINGS USA, INC., FIDELITY AND GUARANTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, rescinding a prior finding that the applicant failed to establish a plainly erroneous fact in an Independent Medical Review (IMR) determination. The Board found the IMR decision was based on a plainly erroneous mistake of fact because it evaluated a request for dorsal medial branch block injections as though it were a request for facet injections, which are different procedures. Consequently, the medical treatment dispute is remanded to the Administrative Director for review by a different independent review organization or reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.5Plainly Erroneous Finding of FactMedical Treatment DisputeUtilization ReviewAdministrative DirectorDorsal Medial Branch BlockFacet InjectionsMTUS Guidelines
References
Case No. ADJ6524043, ADJ5825490
Regular
Mar 17, 2014

TERESITA RUVALCABA vs. CALIFORNIA COMMUNITY NEWS, ZURICH AMERICAN INSURANCE COMPANY

This case concerns Dr. Svastits' lien claim for medical treatment provided to the applicant. The Workers' Compensation Appeals Board (WCAB) denied Dr. Svastits' petition for reconsideration, upholding the WCJ's decision. The WCJ awarded payment only for the new patient consultation and evaluations between July 10, 2008, and September 17, 2011, finding other treatments inconsistent with ACOEM Guidelines. Dr. Svastits' argument that lack of utilization review excused his burden of proof was rejected, as lien claimants must independently prove treatment reasonableness and necessity, consistent with guidelines.

RuvalcabaSvastitsZurichGallagher BassettWCABPetition for ReconsiderationJoint Findings and AwardUtilization ReviewACOEM GuidelinesLabor Code 3202.5
References
Case No. ADJ9694948
Regular
Feb 01, 2016

ESTHER SANDOVAL vs. SAN DIEGO UNIFIED SCHOOL DISTRICT, YORK RISK SERVICES GROUP

The Workers' Compensation Appeals Board denied San Diego Unified School District's petition for reconsideration of an award finding applicant entitled to right shoulder surgery. The defendant argued that the medical opinions supporting the surgery were not substantial evidence because they didn't cite MTUS/ACOEM guidelines or explain non-compliance. The Board affirmed the original finding, agreeing with the WCJ that citing the MTUS is not strictly required if the medical evidence is otherwise compelling and consistent with the guidelines. While one commissioner concurred, he disagreed with the majority's assertion that MTUS citation is not necessary for compliance with Labor Code section 4604.5.

Workers' Compensation Appeals BoardSan Diego Unified School DistrictYork Risk Services GroupPetition for ReconsiderationFindings Award and OrderIndustrial InjuryFurther Medical TreatmentRight Shoulder SurgeryMedical Treatment Utilization ScheduleACOEM guidelines
References
Case No. ADJ9197803
Regular

CHRISTOPHER TORRES vs. CONTRA COSTA SCHOOLS INSURANCE GROUP, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied Christopher Torres's petition for reconsideration of an Independent Medical Review (IMR) determination. The Board found that the applicant failed to prove, by clear and convincing evidence, any of the limited grounds for appeal specified in Labor Code section 4610.6(h). Specifically, the Board agreed with the WCJ that whether the IMR reviewer correctly applied medical guidelines involves expert opinion, not a matter of ordinary knowledge. Therefore, the Board upheld the IMR decision.

WCABPetition for ReconsiderationLabor Code Section 4610.6Administrative DirectorMedical ReviewIndependent Medical Reviewer (IMR)MTUS guidelinesACOEM guidelinesClear and convincing evidencePlainly erroneous finding of fact
References
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