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

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. ADJ9366278
Regular
Nov 18, 2014

JASON ALLEN vs. PROVIDENCE HOLY CROSS HOSPITAL

This case involves a defendant hospital's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The WCAB previously found the hospital's utilization review denial untimely, thus retaining jurisdiction to determine the necessity of the applicant's artificial disc replacement surgery. The WCAB affirmed the finding that the surgery was reasonably necessary, amending the basis for the untimely denial to focus on service notification errors. The defendant argued the administrative rules regarding notification to counsel conflicted with Labor Code section 4610, but the WCAB found no such conflict, upholding its prior decision.

Workers' Compensation Appeals BoardUtilization ReviewTimelinessJurisdictionArtificial Disc ReplacementMedical NecessityPrimary Treating PhysicianAdministrative RulesLabor CodeIndependent Medical Review
References
Case No. FRE 191206
Regular
Nov 20, 2007

MARY SEPEDA vs. SEPEDA BROTHERS DAIRY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION on behalf of FREMONT INDEMNITY, in liquidation, REPUBLIC INDEMNITY

This case involves an applicant seeking reconsideration of a workers' compensation award concerning a low back injury sustained through July 13, 1995. The applicant, supported by her treating physician, argued for additional disc replacement surgery at the L4-5 level beyond the previously awarded L5-S1 spinal fusion. The Workers' Compensation Appeals Board granted reconsideration and amended the award to include the L4-5 disc replacement surgery, finding it reasonably required to cure or relieve the applicant's injury based on the treating physician's opinion.

CIGAFremont IndemnityRepublic Indemnitylow back injurypermanent disabilityfurther medical treatmentspinal surgeryL5-S1 fusionL4-5 disc replacementtreating physician
References
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
Case No. ADJ351902 (OAK 310455) ADJ2725303 (OAK 324531)
Regular
Sep 30, 2008

PHILMORE KING vs. RANEY GEO TECHNICAL, ST. PAUL FIRE & MARINE INSURANCE COMPANY

The WCAB affirmed the WCJ's decision to apply the 1997 disability rating schedule because a treating physician's report indicated permanent disability before January 1, 2005, despite not stating the condition was permanent and stationary.

Workers' Compensation Appeals BoardPhilmore KingRaney Geo TechnicalSt. Paul Fire & Marine Insurance CompanyOpinion and Decision After ReconsiderationFindings Award & OrderWorkers' Compensation Administrative Law JudgeWCJIndustrial InjurySpine Injury
References
Case No. ADJ4686491 BAK 0145318
Regular
May 01, 2012

JOSE GOMEZ vs. CASTLE & COOKE, INC., dba SEVEN OAKS COUNTRY CLUB, ZURICH AMERICAN INSURANCE COMPANY

The Applicant sought reconsideration of a Workers' Compensation Appeals Board (WCAB) decision awarding 34% permanent disability for back and psyche injuries, arguing the award lacked substantial medical evidence. The WCAB denied reconsideration, adopting the judge's report which found the applicant's arguments unconvincing. One commissioner dissented, believing the medical evidence from the defendant's QME was insufficient and that the applicant's QME's higher impairment rating should have been adopted. The dissenting commissioner also admonished the applicant's attorney for improperly attaching exhibits to the petition.

WCABIndustrial injuryPermanent disabilityApportionmentPetition for reconsiderationEvidentiary rulingsFindings of factAwardSubstantial medical evidenceMedical reports
References
Case No. SRO 0135735
Regular
Nov 06, 2007

ROBERT ANUSEWICZ vs. JOINT INDUSTRY BOARD OF PLUMBING, dba KONOCTI HARBOR INN AND RESORT, STATE COMPENSATION INSURANCE FUND

This case concerns an applicant's entitlement to temporary disability indemnity beyond the standard 104-week limit. The Appeals Board rescinded the prior award, ruling that the applicant's hip and knee replacement surgeries did not constitute "amputations" as defined by Labor Code section 4656(c)(2)(C). Therefore, the applicant is limited to 104 weeks of temporary disability indemnity from the commencement of payments, precluding indemnity beyond January 31, 2007.

Workers' Compensation Appeals BoardRobert AnusewiczJoint Industry Board of PlumbingKonocti Harbor Inn and ResortState Compensation Insurance FundSRO 0135735Opinion and Decision After Reconsiderationtemporary disability indemnityindustrial injuryleft knee
References
Case No. ADJ1384238 (SAC 0366460)
Regular
Oct 09, 2017

ROSA VIRGEN vs. MACY'S WEST, MACY'S CORPORATE SERVICES-RISK MANAGEMENT DEPARTMENT

The Workers' Compensation Appeals Board denied Macy's West's petition for removal, upholding the WCJ's decision not to grant a replacement Qualified Medical Evaluator (QME). The Board found that a late supplemental report alone does not mandate a replacement QME under LC 4062.5 or AD Rule 31.5(a)(12). Granting a replacement QME for untimely supplemental reporting is discretionary and requires a showing of good cause, which Macy's failed to demonstrate. The Appeals Board retains exclusive jurisdiction over the validity of replacement panels.

Workers' Compensation Appeals BoardPetition for RemovalQualified Medical EvaluationPQMEReplacement PanelMedical DirectorTimelinessSupplemental ReportGood CausePrejudice
References
Case No. ADJ15951486, ADJ15951487
Regular
Aug 25, 2025

JEFF CRAIL vs. AMTRUST NORTH AMERICA, HARTFORD FIRE INSURANCE COMPANY

The defendant, Amtrust North America and Hartford Fire Insurance Company, filed a Petition for Reconsideration of a Joint Findings of Fact and Orders (F&O) issued on May 20, 2025. The F&O had ordered the replacement of Panel Qualified Medical Examiner (PQME) Dr. Wiseman due to his failure to properly serve his report. The defendant argued that the court improperly interpreted Administrative Director Rule 31.5(a)(12) and that a Declaration of Readiness (DOR) does not constitute both an objection and a request for a replacement panel. The Appeals Board denied the Petition for Reconsideration, affirming the WCJ's decision to replace Dr. Wiseman. The Board's decision cited its en banc ruling in Vazquez v. Inocensio Renteria, reinforcing that a QME's failure to timely issue and serve a report, and engaging in ex parte communication by serving only one party, grants a party the right to seek replacement. The Board also emphasized the informal nature of pleadings in workers' compensation proceedings, as established in Perez v. Chicago Dogs, when addressing the applicant's DOR.

PQMEPetition for ReconsiderationJoint Findings of Fact and OrdersAdministrative Director RuleDeclaration of ReadinessIrreparable HarmMandatory Settlement ConferenceOncology PanelQualified Medical ExaminerProof of Service
References
Case No. ADJ6794293
Regular
Jul 29, 2011

SHARON HIRONYMOUS vs. CENTRAL ANESTHESIA SERVICE, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Workers' Compensation Appeals Board dismissed the defendant's petition for reconsideration of an order allowing a replacement QME panel. The Board granted removal, rescinded the order, and ruled the applicant was not entitled to a replacement QME. This decision was based on the applicant's failure to object to the QME's conduct during the examination itself, instead waiting until after reviewing the QME's report. Allowing a replacement panel under these circumstances was deemed prejudicial to the defendant.

QMEreplacement panelPetition for ReconsiderationPetition for Removalindustrial injurycarpal tunnel syndromeAdministrative Law JudgeQualified Medical Evaluator Complaint FormTitle 8 California Code of Regulationsinterlocutory procedural order
References
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