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

Case No. RDG 0115958
Significant

Brice Sandhagen, Applicant vs. Cox & Cox Construction, Inc., State Compensation Insurance Fund

The Board dismisses the applicant's petition for reconsideration because it was made from an interlocutory (non-final) order, as the matter had been remanded to a WCJ for further proceedings. The Board also observes that utilization review is not a mandatory prerequisite for a defendant to use the QME/AME process.

WORKERS' COMPENSATION APPEALS BOARDEN BANCOPINION AND ORDER DISMISSING PETITION FOR RECONSIDERATIONBrice SandhagenCox & Cox ConstructionInc.State Compensation Insurance FundLabor Code section 4610(g)(1)utilization reviewWCJ
References
Case No. ADJ7136909
Regular
Apr 16, 2014

BRUCE TABARACCI vs. WASTE MANAGEMENT, ACE AMERICAN, GALLAGHER BASSETT

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration and dismissed their petition for removal. The Board adopted the findings of the Administrative Law Judge, who recommended denial. The defendant's arguments, including claims that utilization review (UR) denials were not defective and that Dr. Light's reports were inadmissible, were rejected. The Board found the UR process was procedurally deficient due to the defendant failing to provide all relevant medical records.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalWCJ Report and RecommendationLabor Code §4062IMR tractPrimary Treating Physician (PTP)Secondary Treating PhysicianUtilization Review (UR)Request for Medical Treatment Authorization
References
Case No. ADJ3406569
Regular
Apr 09, 2009

JOSEPH NOVAK vs. SIERRA PACIFIC INDUSTRIES, SIERRA PACIFIC REDDING

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration. The applicant sought penalties and attorney fees, arguing the defendant unreasonably delayed a dorsal column stimulator by undertaking Utilization Review despite a prior Agreed Medical Evaluator's recommendation. The Board affirmed their prior decision, finding the defendant's actions were not unreasonable, as their claims examiner followed proper procedure by initiating UR for a non-routine treatment. The Board cited the Supreme Court's decision in *Sandhagen* to support their conclusion that UR is the appropriate process for evaluating treatment requests.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 5814Labor Code Section 5814.5Agreed Medical EvaluatorDorsal Column StimulatorUnreasonable DelayPenaltyAttorney's FeesSandhagen
References
Case No. ADJ4503834 (VNO 0113665) ADJ3103605 (VNO 0113666) ADJ2309113 (VNO 0113667) ADJ2270309 (VNO 0113668)
Regular
May 18, 2009

MARIA GARCIA vs. CITY OF LOS ANGELES

The Appeals Board dismissed the applicant's petition for reconsideration as it was not from a final order. However, the Board granted removal, rescinded the WCJ's order suspending submission, and returned the case for further proceedings. The WCJ improperly suspended proceedings without statutory authority and failed to resolve issues including utilization review compliance under *Sandhagen*. The Board ordered the WCJ to first address *Sandhagen* issues and proper utilization review before any further medical record development.

Petition for ReconsiderationPetition for RemovalOrders Suspending Submissionsubstantial evidenceutilization reviewuntimelyunsignedpenaltyattorney's feesneglect and delay
References
Case No. ADJ4047184 (RDG 0115958)
Regular
Dec 02, 2009

BRICE SANDHAGEN vs. STATE COMPENSATION INSURANCE FUND

The court affirmed the WCJ's decision that the defendant was barred from relying on the utilization review process due to missed deadlines. The UR process is the employer's only avenue for resolving treatment requests.

RemittiturUtilization ReviewLabor Code section 4610(g)(1)Labor Code section 4062(a)Treating Physician RecommendationWCJFindings and Award and OrderPetition for ReconsiderationEn Banc DecisionCourt of Appeal
References
Case No. ADJ3135829 (AHM 0099139)
Regular
Jul 28, 2014

CAROLYN BERTRAND vs. COUNTY OF ORANGE, YORK

This case concerns a dispute over medical treatment disputes between an applicant and the County of Orange. The parties had previously stipulated to have the Agreed Medical Examiner (AME), Dr. Wilson, resolve future treatment disputes, potentially bypassing the statutory Utilization Review (UR) and Independent Medical Review (IMR) processes. The Workers' Compensation Appeals Board (WCAB) dismissed the employer's petition for reconsideration as the prior order was procedural, but granted removal. As a decision after removal, the WCAB clarified that while the stipulation to use the AME is valid and can supersede IMR, treatment requests must first go through UR, and only subsequent disputes are referred to the AME.

StipulationAgreed Medical ExaminerAMEUtilization ReviewURIndependent Medical ReviewIMRRemovalPetition for ReconsiderationLabor Code section 4610
References
Case No. ADJ380850 (SAL 0117839)
Regular
Apr 26, 2011

Sandra Corona vs. LOS APTOS CHRISTIAN FELLOWSHIP CHILDCARE, CHURCH MUTUAL INSURANCE COMPANY

This case involves a defendant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The original decision awarded the applicant further medical treatment, including a cervical radiofrequency ablation. The defendant argued that the applicant failed to follow the proper Labor Code Section 4062 process after their utilization review denied the treatment request. The majority of the WCAB denied reconsideration, holding that an applicant is not strictly required to use Section 4062 to dispute a utilization review denial and may proceed to an expedited hearing, especially when the employer failed to provide adequate information for the review. However, one commissioner dissented, arguing that Section 4062 mandates a dispute resolution process following utilization review.

Workers' Compensation Appeals BoardLabor Code Section 4610Labor Code Section 4062Utilization ReviewReconsiderationFindings and AwardPrimary Treating PhysicianExpedited HearingAgreed Medical ExaminerQualified Medical Examiner
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. ADJ8419958
Regular
Jan 16, 2014

FELIPE RAMIREZ vs. D'ARCY & HARTY CONSTRUCTION, INC., OLD REPUBLIC GENERAL INSURANCE CORPORATION

This case involves a worker's compensation applicant, Felipe Ramirez, seeking approval for spinal surgery recommended by his treating physician, Dr. Naraghi. The defendants contested the surgery, and Utilization Review initially denied the request. The Administrative Law Judge (ALJ) awarded the surgery, finding the UR denial invalid as the reviewing doctor lacked crucial medical information. The Appeals Board denied the defendants' petition for reconsideration, affirming the ALJ's decision.

Workers' Compensation Appeals BoardPetition for ReconsiderationDenialSpinal surgeryDr. NaraghiUtilization ReviewNon-certificationDr. DeutschSandhagenLabor Code §4610
References
Case No. ADJ8303588
Regular
Nov 26, 2012

ROLANDO IBARRA vs. C.W. BROWER, INC., COMPANION PROPERTY CASUALTY, INC.

The applicant sought reconsideration of an order directing a medical-legal evaluation concerning a proposed shoulder surgery. The Appeals Board dismissed the petition because the WCJ's order was an interim procedural ruling, not a final determination of substantive rights or liabilities. Therefore, it was not subject to reconsideration. Even if considered, the petition would likely be denied due to waiver of service objections and insufficient evidence to overturn the UR physician's conclusion.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization ReviewLabor Code Section 4610Medical-Legal EvaluationLabor Code Section 4062Final OrderInterim OrderSubstantive RightLiability
References
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