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

Case No. ADJ1424522 (SDO 0299397)
Regular
Mar 29, 2018

PETER WINOKUR vs. MONTEREY FINANCIAL SERVICES, FARMERS INSURANCE GROUP

The Workers' Compensation Appeals Board (WCAB) affirmed a judge's decision denying the applicant's claim for acupuncture and lidocaine patches. The applicant argued that acupuncture was not subject to utilization review (UR) based on *Patterson v. The Oaks Farm*, but the Board found *Patterson* inapplicable as there was no evidence of ongoing authorization for acupuncture. All Independent Medical Review (IMR) determinations upholding UR denials were affirmed, as the WCAB's review of IMR decisions is limited to specific grounds. The applicant failed to present clear and convincing evidence of plainly erroneous factual findings by IMR.

Workers Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeFindings and OrderMedical TreatmentAcupunctureLidocaine PatchesUtilization ReviewIndependent Medical Review (IMR)Patterson v. The Oaks Farm
References
Case No. ADJ4260469 (SRO 0081378)
Regular
Jul 13, 2012

JEFFREY KRESS vs. DEPARTMENT OF TRANSPORTATION, STATE OF CALIFORNIA, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration to modify a previous order regarding unreasonably delayed payments for acupuncture treatments and an orthopedic bed. The Board removed the $4,400 Labor Code section 5814.5 attorney's fee, finding it inapplicable to the State of California. They increased the penalty for unreasonable delay to 25% and awarded applicant's attorney a 10% fee on that penalty. The Board also clarified that Labor Code section 5800 interest is due on specific acupuncture visits post-stipulation and award, but not on the orthopedic bed as it lacked a specific award.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderAcupunctureOrthopedic bedLabor Code section 5814.5Attorney's feePrejudgment interestSection 5800 interestStipulation and Award
References
Case No. ADJ3496351 (SAC 0319422)
Regular
Sep 27, 2010

SANDRA L. BOYD vs. COUNTY OF SACRAMENTO

This case concerns whether lien claimant MBM Boutique Acupuncture could bill for multiple units of electro-acupuncture (CPT code 97801) per session. The defendant, County of Sacramento, argued that under the Official Medical Fee Schedule (OMFS), 97801 is an untimed code billable only once per session. The Appeals Board reversed the WCJ's decision, finding the defendant's expert bill reviewer's unrebutted testimony established 97801 as an untimed code, limiting reimbursement to one unit per session. Therefore, the defendant's payment was deemed reasonable and consistent with the OMFS, and the lien claimant was awarded nothing further.

Official Medical Fee ScheduleOMFS97801timed proceduresuntimed proceduresdeputy sheriffacupuncturereimbursementbill reviewerunit per session
References
Case No. ADJ2122972 (POM 0291979)
Regular
Sep 17, 2009

ROGELIO NUNEZ vs. RAYMOND INTERIOR SYSTEMS, ZURICH NORTH AMERICA

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded the prior decision regarding a \$23,000 lien claim for acupuncture. The WCAB found that the employer's utilization review (UR) process for the recommended acupuncture treatment was unclear and ordered the case returned to the trial level. This re-examination is to determine if the employer timely conducted UR on the treating physician's recommendations for acupuncture. Additionally, the WCAB noted that the 24-session limitation does not apply to acupuncture.

Workers' Compensation Appeals BoardRogelio NunezRaymond Interior SystemsZurich North AmericaADJ2122972POM 0291979Opinion and Order Granting ReconsiderationLien ClaimSanta Anita Acupuncture CenterOfficial Medical Fee Schedule
References
Case No. ADJ2544321 (VNO 0546971)
Regular
Jan 04, 2010

PEDRO SERRATO vs. B & B DOORS & WINDOWS, INC., PRAETORIAN INSURANCE COMPANY C/O AMERICAN ALL RISK LOSS ADMINISTRATORS

The Workers' Compensation Appeals Board dismissed the defendant's Petition for Reconsideration as untimely, as it was filed 44 days after the deadline. The Board, however, corrected a clerical error in the original Findings and Award. The Judge had awarded $12,425.48 to a lien claimant, but the corrected award reflects the statutory limit of 24 chiropractic visits, along with physical therapy and acupuncture, totaling $3,740.61 based on expert testimony.

Workers' Compensation Appeals BoardPedro SerratoB & B Doors & WindowsPraetorian Insurance CompanyPacific Ortho & RehabilitationFindings and Awardclerical errorpetition for reconsiderationuntimelyLabor Code section 5903
References
Case No. ADJ563768 (SBR 0331684), ADJ2410618 (SBR 0338943)
Regular
Mar 22, 2010

JORGE GONZALEZ vs. TOYO TIRE USA, TOKO MARINE PASADENA

Lien claimant Access Health Medical Group seeks full reimbursement for services, arguing the WCJ erred by disallowing most of its lien based on anti-referral laws (Labor Code §§ 139.3, 139.31). Access contends these laws do not apply to in-house referrals for chiropractic, acupuncture, or "work conditioning" services, as these are not "physical therapy." The Appeals Board granted reconsideration, finding the WCJ applied an overly broad definition of physical therapy. The case is returned for further proceedings to determine if the billed services were distinct from physical therapy, or if "work conditioning" constitutes physical therapy under the statute.

Labor Code §§ 139.3Labor Code § 139.31anti-referral lawsin-office referralsphysical therapychiropracticacupuncturework conditioninglien claimantFindings and Order
References
Case No. ADJ7616809
Regular
Apr 26, 2013

Salvador Mora vs. Scheenstra Dairy, York Claims Services

The Workers' Compensation Appeals Board dismissed Angel Acupuncture's Petition for Reconsideration because it was untimely filed. The lien claimant failed to timely file their objection to the dismissal of their lien claim. Even if the petition had been timely, the Board found no good cause to overturn the dismissal. The Board adopted and incorporated the reasoning of the administrative law judge's report and recommendation.

Workers' Compensation Appeals BoardPetition for ReconsiderationDismissalUntimely FilingLien ClaimantAngel AcupunctureAdministrative Law JudgeNotice of Intent to DismissGood CauseCCP §473(b)
References
Case No. OAK 242409, OAK 242410
Regular
Nov 11, 2008

TINA CHASE vs. BOB'S FOAM FACTORY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, SUPERIOR NATIONAL INSURANCE COMPANY, BROADSPIRE

The WCAB granted reconsideration, affirming the applicant's award for acupuncture treatment as recommended by Dr. Lin. However, the Board denied attorney fees under Labor Code sections 5814 and 5814.5 due to the defendant's arguments regarding delay and date of injury applicability. The issue of attorney fees under Labor Code section 4607 was deferred pending California Supreme Court decisions addressing similar attorney fee disputes.

Workers' Compensation Appeals BoardBob's Foam FactoryCalifornia Insurance Guarantee AssociationSuperior National Insurance CompanyBroadspirePetition for ReconsiderationAcupuncture TreatmentDr. LinLabor Code section 5814.5Attorney Fees
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. ADJ3473535
Regular
Jul 22, 2014

BARBARA DANGERFIELD vs. AMERICAN COMPANION & HOMEMAKER SERVICES, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted South Lake Medical Center's Petition for Removal, rescinding a prior order that compelled specific witnesses to appear and threatened lien dismissal and sanctions. The Board found the order imposed undue prejudice on South Lake, mischaracterized a medical expert as a percipient witness, and lacked legal basis for lien dismissal based on witness non-appearance. While the request for WCJ disqualification was untimely, the trial date remains.

Petition for RemovalWCJ OrderPercipient WitnessMedical ExpertLien DismissalSanctionsWCAB Rule 10606Compromise and ReleaseChiropractic VisitsLabor Code 4604.5
References
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