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

Case No. ADJ290453
Regular
Apr 11, 2014

MANUEL GOMEZ vs. FACILITIES SUPPORT SERVICES, COMPWEST INSURANCE COMPANY

This case concerns a workers' compensation applicant seeking medical treatment for his knees and compensation for gastrointestinal injury. The Appeals Board granted the applicant's petition for reconsideration, finding the defendant's utilization review process for left knee treatment was procedurally deficient. As a result, the issue of left knee treatment is deferred for further determination at the trial level. The applicant's claims of new and further gastrointestinal disability are not time-barred, but any permanent disability that existed prior to a 2011 settlement is barred by estoppel and res judicata.

Workers' Compensation Appeals BoardPetition for ReconsiderationIndependent Medical Review (IMR)Utilization Review (UR)Senate Bill 863 (SB 863)Dubon v. World RestorationInc.Procedural DefectsMedical NecessityNew and Further Disability
References
1
Case No. ADJ982471 (LAO 0859620)
Regular
Apr 28, 2014

JUVENCIO TORRES-RAMOS vs. FELIX MARQUEZ, REDWOOD FREE INSURANCE COMPANY, BERKSHIRE HATHAWAY

The Workers' Compensation Appeals Board denied the defendant's petition for removal and dismissed the applicant's petition for reconsideration. The Board adopted the WCJ's report, finding that the defendant failed to show significant prejudice or irreparable harm to warrant removal. The applicant voluntarily withdrew their reconsideration petition after understanding that their pain management treatment request lacked the required authorization form. The case was referred to the Independent Medical Review (IMR) process for a decision on the applicant's need for pain management treatment.

WCABPetition for RemovalPetition for ReconsiderationIndependent Medical ReviewIMRsubstantial evidenceutilization reviewtimelyprimary treating physicianDWC Form PR-2
References
1
Case No. ADJ10064259
Regular
Nov 19, 2015

, Applicant, CHARLES WAGNER, vs. , Defendants. BARRETT BUSINESS SERVICES; ACE AMERICAN INS. CO.; CORVEL ADMINSTRATOR

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior order allowing the applicant to treat outside the defendant's Medical Provider Network (MPN). The Board found that while MPN notice requirements are crucial, an employee can only treat outside the network at the employer's expense if a failure to provide notice resulted in a denial of medical care. In this case, the applicant received timely medical treatment, and the defendant presented evidence of providing MPN notices, thus, the applicant was not entitled to self-procured treatment outside the MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)ReconsiderationFindings and OrderAdministrative Law Judge (WCJ)Labor CodeRule 9767.12Medical TreatmentExpedited HearingForklift Operator
References
1
Case No. ADJ3852069 (STK 0175466)
Regular
Dec 29, 2015

RAFAEL GOMEZ vs. DAVID REICH CONSTRUCTION, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted the applicant's petition for reconsideration, finding that the Independent Medical Review (IMR) determination was untimely. The WCAB rescinded the previous ruling and entered a new finding that the IMR was not completed within the mandatory timeframes outlined in Labor Code section 4610.6(d). Consequently, the medical treatment dispute is no longer subject to the IMR process and is returned to the trial level for a WCJ to decide. This ruling prioritizes the applicant's right to timely medical treatment, emphasizing that mandatory timeframes are crucial for protecting injured workers.

IMRLabor Code section 4610.6(d)WCAB jurisdictiontimely completionmedical treatment disputeadministrative law judgepetition for reconsiderationfindings of factutilization reviewMaximus
References
19
Case No. ADJ9290138
Regular
Jul 14, 2016

MATT JACOBS vs. PARSEC, INC./BUDCO; ACE USA

This case denied an applicant's petition for reconsideration of a decision upholding an Independent Medical Review (IMR) denial of knee surgery authorization. The applicant argued the IMR determination was invalid due to untimeliness, but the Board found the statutory timeframes for IMR decisions are directory, not mandatory. Therefore, a delay in the IMR decision does not invalidate it, and the applicant remains bound by the IMR's finding on the medical necessity of the proposed treatment. The Board affirmed the WCJ's decision, denying the applicant's petition for reconsideration.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code section 4610.6(h)Utilization ReviewTotal ArthroplastyTimelinessAdministrative DirectorPlainly Erroneous Finding of FactDirectory vs. MandatoryMargaris
References
4
Case No. ADJ1901810 (SAC 0362345) ADJ381755 (SAC 0362346)
Regular
Feb 03, 2010

RONALD WILLIAMS vs. MV TRANSPORTATION, INC.; AMERICAN HOME ASSURANCE, adjusted by BROADSPIRE

The Workers' Compensation Appeals Board (WCAB) dismissed the applicant's petition for reconsideration as it was untimely filed and not properly verified. The WCAB also denied the defendant's petition for reconsideration, adopting the reasoning of the Workers' Compensation Judge. The underlying decisions found the applicant sustained an industrial injury to his low back, requiring further treatment but no permanent disability. A separate decision found an industrial injury to his right upper extremity (CRPS) and neck/upper back (myofascial pain syndrome), resulting in 75% permanent disability and entitlement to further medical treatment.

Complex Regional Pain SyndromeMyofascial Pain SyndromeAgreed Medical EvaluatorAMA Guides 5th EditionLabor Code section 4658(d)Permanent Disability IndemnityPetition for ReconsiderationUntimely FilingLack of VerificationJurisdictional Time Limit
References
9
Case No. ADJ2068970 (STK 0167616)
Regular
Aug 20, 2015

Norman McAtee vs. Briggs & Pearson Construction, State Compensation Insurance Fund

The Workers' Compensation Appeals Board granted the applicant's petition for reconsideration, finding that the Administrative Director's prior Independent Medical Review (IMR) determination was based on plainly erroneous findings of fact. The Board concluded that the IMR wrongly stated there was no documentation of improved function or reduced pain with the applicant's Duragesic patches, citing medical reports and applicant testimony to the contrary. Therefore, the IMR decision was rescinded, the applicant's appeal was granted, and the treatment dispute was remanded for a new IMR.

WCABPetition for ReconsiderationIndependent Medical ReviewLabor Code Section 4610.6(h)Plainly Erroneous Findings of FactAdministrative DirectorDuragesicOpioid AnalgesicsPermanent DisabilityMedical Treatment
References
0
Case No. ADJ7781676
Regular
Nov 01, 2017

TERESA HERNANDEZ vs. T K & J, INC., dba LAS PALMAS RESTAURANT, PREFERRED EMPLOYERS INSURANCE COMPANY

This case involves a lien claim by Comprehensive Outpatient Surgery Center for medical treatment provided to applicant Teresa Hernandez. The applicant sustained a complex injury in 2010, and the employer provided some treatment through Dr. Lane, an MPN physician, including surgeries. The lien claimant contended that proper MPN notice was not provided and that the applicant was therefore entitled to seek treatment outside the MPN. However, the Appeals Board denied reconsideration, finding that the lien claimant failed to demonstrate that any lack of notice resulted in a denial of reasonable medical treatment, a burden of proof established by statute. Therefore, the employer was not liable for the applicant's self-procured treatment with non-MPN providers.

MPNLien ClaimantPetition for ReconsiderationFindings and OrderMedical Provider NetworkReasonably Necessary Medical TreatmentSelf-ProcureBurden of ProofLabor CodeSB 863
References
4
Case No. ADJ4523909
Regular
Mar 04, 2016

GLORIA BLACKMON vs. ABZ AUTO WRECKAGE, TRUCK INSURANCE COMPANY, FARMERS INSURANCE EXCHANGE

This case concerns an applicant's petition for reconsideration of a denial of medical treatment authorization. The Workers' Compensation Appeals Board (WCAB) denied the petition, upholding the administrative law judge's decision. The key issue was whether an untimely Independent Medical Review (IMR) determination invalidates the IMR process, thereby allowing the WCAB to decide treatment necessity. The majority found the IMR timelines to be directory, not mandatory, and thus the untimely IMR was valid and binding. A dissenting commissioner argued the IMR timelines are mandatory, and an untimely IMR should allow the WCAB to determine treatment necessity.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewSB 863Labor Code section 4610.6(h)Administrative Directormandatory vs. directorymedical treatment disputeprescription medicationsWellbutrin
References
27
Case No. ADJ1775896 (RDG 0101688), ADJ2010679 (RDG 0104042)
Regular
Nov 28, 2012

RICHARD SEILER vs. CARDIOLOGY ASSOCIATES OF NORTHERN CALIFORNIA, STATE COMPENSATION INSURANCE FUND

The applicant, Richard Seiler, petitioned to recuse the judge, alleging prejudice and improper rulings on evidence and medical treatment requests. The Workers' Compensation Appeals Board (WCAB) reviewed the applicant's filings and the judge's report. The WCAB denied the disqualification petition, finding no evidence of bias. The applicant will have the opportunity to raise these issues at trial and, if necessary, file a petition for reconsideration.

Recusal petitionJudge JonesLabor Code section 5311WCAB Rule 10452Chiropractic QMEExclusion of evidencePrescribing physicianHormone replacementMandatory settlement conferencePetition for reconsideration
References
0
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