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

Case No. ADJ9038700
Regular
Sep 06, 2017

RAFAEL GONZALEZ vs. GORDON HAY, INC., ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the employer's petition for reconsideration. The Board affirmed the administrative law judge's order for continued treatment at Casa Colina for the applicant's traumatic brain injury (TBI). This decision was based on a prior Independent Medical Review (IMR) finding that Casa Colina treatment was reasonable and no evidence of changed condition. Furthermore, the employer's failure to conduct timely utilization review for the requested treatment authorized the Board to determine medical necessity based on substantial evidence.

Workers Compensation Appeals BoardTraumatic Brain Injury (TBI)Independent Medical Review (IMR)Utilization Review (UR)Findings and OrderPetition for ReconsiderationSubstantial Medical EvidenceIndustrial InjuryMedical TreatmentCasa Colina
References
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
Case No. SAC 306565, SAC 306566, SAC 310519
Regular
Mar 18, 2008

GILBERT A. JONES, SR. vs. TRANSITIONAL COMMUNITY LIVING CENTER, STATE COMPENSATION INSURANCE FUND

This case involves an applicant who sustained industrial injuries in 2001 and 2002. The WCJ initially ruled to combine all injuries under the Wilkinson Doctrine for permanent disability, but the defendant sought reconsideration. The Appeals Board affirmed the WCJ's decision except for the findings on permanent disability and apportionment, remanding these issues for further development and application of the Benson decision, which replaced the Wilkinson Doctrine with a causation-based apportionment regime.

Workers' Compensation Appeals BoardReconsiderationPermanent DisabilityApportionmentWilkinson DoctrineLabor Code Sections 4663Labor Code Sections 4664Brodie DecisionFuentes DecisionBenson Decision
References
Case No. ADJ9743742
Regular
Jan 25, 2018

AGUSTIN CASTRO GONZALEZ vs. TRADEMARK CONSTRUCTION COMPANY, INC., ZURICH AMERICAN INSURANCE COMPANY

The applicant sought reconsideration of a Workers' Compensation Appeals Board (WCAB) decision denying 24/7 home custodial care and limiting Casa Colina treatment to four weeks. The WCAB granted reconsideration, amending the decision to defer the issue of 24/7 home health care pending further record development. The WCAB affirmed the original finding that Casa Colina treatment for four weeks was reasonable and necessary, stating that any need for further treatment could be processed normally.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact Award and OrdersWorkers' Compensation Administrative Law JudgeCustodial CareCasa ColinaUtilization ReviewExpedited HearingDeclaration of ReadinessMedical Treatment
References
Case No. ADJ16022807
Regular
Aug 08, 2025

ISRAEL MORALES ROJAS vs. CHRISTENSEN BROTHERS GENERAL ENGINEERING, INC., STATE COMPENSATION INSURANCE FUND

Applicant Israel Morales Rojas petitioned for reconsideration of a WCJ's July 7, 2023, decision that denied his entitlement to a specific post-acute residential rehabilitation program. The Appeals Board granted reconsideration to review the matter. While the reconsideration was pending, the Board was advised that a proposed settlement had been reached. Consequently, the Board rescinded the WCJ's original decision and returned the case to the trial level for the WCJ to consider the proposed settlement.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderBurden of ProofReasonableness of TreatmentCasa Colina Transitional Living CenterInterdisciplinary Post-Acute Residential Rehabilitation ProgramSettlementRescindedReturned to Trial Level
References
Case No. ADJ1480264 (FRE 0200339) MF
Regular
Dec 29, 2015

JOSE ACOSTA vs. PETERSON FAMILY, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision concerning the retroactive application of a 2012 statutory fee reduction for ambulatory surgical centers. This decision was made after the defendant, State Compensation Insurance Fund (SCIF), and lien claimant Sierra Pacific Surgical Center (SPSC) reached a settlement agreement. The WCAB returned the case to the trial level for approval of this settlement, allowing the WCJ to reissue the rescinded decision if the settlement is not approved. The original decision had found that the fee reduction did not apply retroactively to services provided before January 1, 2004.

Workers' Compensation Appeals BoardState Compensation Insurance FundSierra Pacific Surgical Centerambulatory surgical centeroutpatient surgical centerMedicare reimbursementSenate Bill 863Labor Code section 5307.1(c)(1)retroactive applicationsettlement agreement
References
Case No. POM 0261983
Regular
Feb 08, 2009

SARA LARA vs. POMONA UNIFIED SCHOOL DISTRICT, CALIFORNIA COMPENSATION INSURANCE/BROADSPIRE

The lien claimant, Premier Outpatient Surgery Center, sought reconsideration of an administrative law judge's decision that reduced their billed costs for applicant's medical treatment. The Workers' Compensation Appeals Board denied the petition, upholding the judge's finding that the billed costs were unreasonable and that the lien claimant failed to present a persuasive case supporting their charges. The Board also found no evidence of a violation of Labor Code section 4603.2 regarding timely reimbursement.

Kunz v. PattersonWCABLien claimantAmended Findings of FactReasonable and necessary costsBilled costs unreasonableStipulations with Request for AwardIndustrial injuryBilateral upper extremitiesNeck injury
References
Case No. OAK 263916
Regular
Jun 04, 2008

JEFFREY HONEYWELL vs. SAFEWAY STORES

The Workers' Compensation Appeals Board denied lien claimant Bay Surgery Center's petition for reconsideration, upholding the administrative law judge's decision to award partial payment for medical services. The Board also dismissed Safeway Stores' petition for reconsideration as untimely filed. Additionally, the Board admonished the lien claimant's representative for unprofessional comments made about the judge.

Bay Surgery Centerdiscographypump proceduresitemized billsLabor Code section 4603.2substantial evidencereasonableness of chargespenalty assessmentpenalty for unreasonable delayfictitious name permit
References
Case No. ADJ7286862, ADJ7604060
Regular
Sep 14, 2015

Kelly Tinsley vs. VERTIS COMMUNICATIONS, ACE USA INSURANCE

This case involves a denial of a defendant's petition for reconsideration regarding a workers' compensation award. The defendant's Utilization Review (UR) of the applicant's requested continued treatment at a residential rehabilitation center was deemed invalid by the Administrative Law Judge (ALJ) due to untimeliness in communication. The Workers' Compensation Appeals Board (WCAB) affirmed the ALJ's decision, finding the UR invalid because the defendant failed to prove timely communication to the physician as required by statute. Consequently, the WCAB upheld the award of continued treatment, deeming it reasonable and supported by substantial medical evidence.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization ReviewUntimelinessRequest for AuthorizationTransitional Living CenterResidential ProgramPost-Acute Physical RehabilitationPsychiatric InjuryIndependent Medical Review
References
Case No. AHM 0082920
Regular
Mar 10, 2008

RAUL REYES vs. DUDDY DRYWALL COMPANY, STATE COMPENSATION INSURANCE FUND

This Workers' Compensation Appeals Board decision denies a lien claimant's petition for reconsideration. The WCAB affirmed the trial judge's disallowance of a medical lien, finding the claimant failed to prove either the reasonableness of its charges or proper licensure for the services provided under the name "SB Surgery Center" on the date of service. The Board held the lien claimant bore the burden of proving licensure and did not meet that burden.

Lien claimantSB Surgery CenterS&B Surgery Centerlicensingreasonableness of chargesburden of proofsubstantial evidenceLabor Code sections 59025904Zenith Insurance Company v. Workers' Comp. Appeals Bd.
References
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