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

Case No. 2016-08-0270
Regular Panel Decision
Jul 12, 2016

Morgan, Debbie v. Macy's Corporate Services

Debbie Morgan, a Macy's sales associate, sustained a right shoulder and neck injury after a fall. The authorized physician, Dr. Samuel Schroerlucke, recommended C4-C6 ACDF surgery. Macy's denied the surgery based on a utilization review by Dr. Robert G. Winans, asserting it was not medically necessary. Ms. Morgan filed a Request for Expedited Hearing for medical benefits. The Court, presided over by Judge Allen Phillips, determined it had the authority to review issues of medical necessity, citing common law and statutory provisions. The Court found that Dr. Schroerlucke's recommendation for surgery was presumed medically necessary, and Macy's failed to rebut this presumption with clear and convincing evidence. The Court noted Dr. Schroerlucke's consistent documentation of findings (positive Spurling's sign, decreased bicep reflexes, radicular complaints) which aligned with the ODG requirements for the surgical procedure. Consequently, the Court ordered Macy's to pay for the recommended surgery and denied Macy's subsequent motion to expand its defenses to include an idiopathic injury.

Workers' CompensationMedical BenefitsExpedited HearingUtilization ReviewMedical NecessitySpinal StenosisCervical Fusion SurgeryC4-C6 ACDFSpurling's SignRadiculopathy
References
5
Case No. 2018-01-0590
Regular Panel Decision
Jul 08, 2019

Buckner, Charles v. Ecolab Manufacturing, Inc.

Charles Buckner, a forklift operator for Ecolab, experienced neck pain after lifting. He underwent a C4-5 and C5-6 fusion surgery in June 2017. Despite initial surgery and conservative treatments, his neck pain and radicular symptoms persisted. Dr. Jason Eck, his authorized orthopedist, recommended further surgery for C5-C6 narrowing, which was twice denied following utilization reviews. The Court, applying the presumption of medical necessity for treatment recommended by an authorized physician, overruled the UR denials. The decision highlighted the treating physician's greater familiarity with the patient compared to non-treating UR physicians.

Medical BenefitsExpedited HearingNeck PainFusion SurgeryUtilization ReviewMedical NecessityTreating PhysicianExpert OpinionDiagnostic TestingTennessee Law
References
3
Case No. ADJ6909910
Regular
Aug 01, 2017

GILBERTO MORALES vs. HERRICK CORP.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and reversed a prior ruling regarding an epidural steroid injection (ESI). The WCAB found that the defendant's initial authorization for an ESI at the C6-C7 level was not superseded by a subsequent request for a more extensive ESI by a new treating physician. The Board determined there was no documented change in the applicant's medical condition to justify further utilization review of the previously authorized C6-C7 ESI. Therefore, the defendant remains obligated to provide the C6-C7 ESI without additional utilization review.

Epidural Steroid InjectionUtilization ReviewPrior AuthorizationChange of PhysicianCervical SpineWCABPetition for ReconsiderationIndependent Medical ReviewPrimary Treating PhysicianRequest for Authorization
References
4
Case No. ADJ14808611
Regular
Sep 16, 2022

KATIE Y. LAM vs. COUNTY OF ORANGE, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns an applicant who sought reconsideration of a workers' compensation award denying her claim for neck injury. The Workers' Compensation Appeals Board granted reconsideration, amending the award to include injury to the cervical spine. This amendment was based on the substantial evidence from a Qualified Medical Examiner (QME) whose reports indicated C6 radiculopathy was causally related to the applicant's employment injury. The Board found the QME's opinion well-reasoned and not contradicted by other evidence.

Cervical radiculopathyQMEAOE/COEPetition for ReconsiderationFindings and AwardSubstantial evidenceCompensable consequenceApportionmentDeputy sheriff traineeAmbulatory imbalance
References
8
Case No. ADJ 11017618
Regular
Oct 29, 2020

Robert Shelven vs. RALPHS GROCERY COMPANY, SEDGWICK CMS, INC.

In this workers' compensation case, the applicant sought reconsideration of a decision denying their petition. The core issue was whether a February 2020 request for a cervical spine epidural injection constituted the "same treatment recommendation" as a previously denied September 2019 request, thereby preventing mandatory utilization review under LC § 4610(k). The Board denied reconsideration, adopting the WCJ's reasoning that the February 2020 request, while for one level instead of two, was for the "same treatment" at C5-C6 which had been denied within the prior 12 months. The Board further agreed that no documented change in facts material to the basis of the prior denial was presented, thus the Court lacked jurisdiction to determine the medical necessity of the treatment.

Utilization ReviewRequest for AuthorizationCervical Spine Epidural InjectionLC § 4610(k)Medical Treatment Utilization ScheduleInternational Medical Reviewtimelinessjurisdictionreasonable and necessaryFindings and Order
References
2
Case No. 2016-05-1257
Regular Panel Decision
May 26, 2017

Joyce Jackson v. University of the South

Joyce Jackson, a custodian at the University of the South, fell down seven concrete steps at work, hitting her head on a railing post. She sought medical and temporary disability benefits for neck, head, and right-shoulder injuries. Dr. Michael Moran, a neurosurgeon, determined that her fall caused a disc herniation at C4-5, leading to progressive cervical myelopathy and requiring urgent surgery. The Court found Ms. Jackson is likely to prove a compensable injury and is entitled to medical treatment and temporary total disability benefits from December 12, 2016, through February 8, 2017. However, the Court denied temporary partial disability benefits due to her voluntary retirement before her disability fully manifested.

Workers' CompensationExpedited HearingMedical BenefitsTemporary Disability BenefitsCervical MyelopathyDisc HerniationWork-Related InjuryCausationIdiopathic FallStaircase Fall
References
12
Case No. MISSING
Regular Panel Decision
Apr 15, 2003

Claim of Paradise v. Goulds Pump

In March 1993, the claimant suffered a cervical and thoracic spine strain/sprain while lifting a heavy carton at work. Although he initially recovered, he later developed recurring neck pain and numbness in his left hand. Neurosurgeon Webster Pilcher diagnosed nerve root compression at C5 and C6, attributing it to the 1993 work-related injury and recommending surgery. The employer's workers’ compensation carrier declined coverage. The Workers’ Compensation Board subsequently found a causal relationship between the injury and the claimant's current condition, authorizing the surgery. The employer and carrier appealed, contending that the Board's finding was based on speculative medical opinion. The court affirmed the Board's decision, finding that Pilcher's opinion had a rational basis and was supported by substantial evidence.

Workers' CompensationNerve Root CompressionCervical SpineThoracic SpineCausationMedical OpinionSubstantial EvidenceNeurosurgeonSpinal InjuryAppeal
References
2
Case No. 2024-50-2857
Regular Panel Decision
Aug 04, 2025

BROWN, MICHAEL v. CITY OF PULASKI ELECTRIC SYSTEMS

Mr. Brown, an employee of City of Pulaski Electric Systems, suffered a work injury to his head, neck, and shoulder. His authorized physician, Dr. Erion Qamirani, recommended a cervical disc fusion surgery and temporary disability benefits, which the employer denied based on utilization review and medical director opinions asserting lack of medical necessity. The Court conducted a de novo review, weighed conflicting medical opinions, and found Dr. Qamirani's opinion more credible due to his specialization, consistent patient contact, and review of actual MRI films. Consequently, the Court granted Mr. Brown's request, ordering Pulaski to authorize the C3-C4 fusion surgery and pay temporary total disability benefits from October 28, 2024, forward.

Cervical Fusion SurgeryMedical Necessity DisputeUtilization ReviewTemporary Total Disability BenefitsOrthopedic Spine SpecialistMRI InterpretationConflicting Medical EvidenceDe Novo ReviewWork Injury CompensationEmployer-Authorized Treatment
References
4
Case No. MISSING
Regular Panel Decision
Oct 02, 1991

Save Audubon Coalition v. City of New York

This case involves petitioners challenging the City of New York's approvals for the Audubon Research Park project in Manhattan, alleging violations of the State Environmental Quality Review Act (SEQRA), City Environmental Quality Review Act (CEQR), and Uniform Land Use Review Procedure (ULURP). Petitioners specifically contested amendments to the Zoning Resolution permitting biological research in C6 zones and the site-specific approvals for the Audubon Research Building, claiming environmental impact statements (EIS) were flawed regarding public health and safety and that public notice was inadequate. The court determined that respondents had adequately addressed environmental concerns, provided reasoned elaborations, and fulfilled public notice requirements, despite minor procedural omissions. Consequently, the lower court's judgment was affirmed, validating the Board of Estimate's rationally based and non-arbitrary decisions.

Environmental ReviewZoning AmendmentsLand Use PlanningSEQRACEQRULURPPublic HearingsManhattan DevelopmentUrban RenewalBiomedical Research Facilities
References
8
Case No. 2018-07-0621
Regular Panel Decision
Jun 18, 2021

Greve, Robert v. Southern Integrated Servs.

This Expedited Hearing Order addresses Mr. Robert Greve's request for medical benefits to cover an anterior cervical discectomy and fusion (ACDF) surgery recommended by his treating physician, Dr. Samuel Murrell, following a work-related neck injury. The employer, Southern Integrated Servs., and its carrier, Bridgefield Casualty Ins. Co., opposed the request, citing opinions from other medical examiners and a Utilization Review that the surgery was neither causally related nor medically necessary, and that the condition was primarily degenerative. The Court denied Mr. Greve's request, finding that Dr. Murrell's testimony, stating the surgery was merely "related to" the work incident, did not meet the statutory requirement of establishing that the employment contributed more than fifty percent to the need for treatment. Furthermore, other medical opinions presented did not support the claim that Mr. Greve would likely prevail at a full hearing on the merits, particularly regarding causation and necessity.

Expedited HearingMedical BenefitsSurgery DenialCausation StandardTennessee Workers' CompensationSpinal InjuryACDF SurgeryOrthopedic SurgeryUtilization ReviewMedical Necessity
References
4
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