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

Case No. ADJ6989761
Regular
Sep 30, 2013

ELVIN SALGUERO vs. CHARLES GEMEINER CABINETS, INSURANCE COMPANY OF THE WEST

This case involves an applicant seeking reconsideration of a denial for 24/7 home care. The applicant argues the denial was an abuse of discretion, as medical evidence supported the need for such care due to suicidal ideation and depression. The Workers' Compensation Appeals Board denied the petition, adopting the judge's report which found no support for 24/7 home care in relevant treatment guidelines. The judge concluded that the applicant failed to prove the requested care was reasonable and necessary beyond the requirements of existing guidelines.

WCABPetition for ReconsiderationHand Surgery EvaluationStellate Block ProceduresHome CarePsychiatric TechnicianLicensed Vocational NurseSuicidal IdeationPsychiatric HospitalizationLabor Code Section 4600(b)
References
Case No. ADJ9264214
Regular
Apr 04, 2016

CRYSTAL FAVILA vs. ARCADIA HEALTH CARE, CYPRESS INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Crystal Favila's Petition for Reconsideration and dismissed her Petition for Removal. The Board found that both the Utilization Review (UR) and Independent Medical Review (IMR) determinations denying Favila's requested surgery were timely. The Board also determined that Favila's argument regarding outdated medical guidelines was a matter of expert opinion, which cannot be overturned under Labor Code section 4610.6(h). Therefore, the WCJ's findings were affirmed, and the denial of the requested treatment was upheld.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationUtilization ReviewIndependent Medical ReviewRequest for Authorizationtimely determinationLabor Code section 4610Official Disability Guidelineplainly erroneous finding of fact
References
Case No. ADJ15329380
Regular
Oct 31, 2025

BERTHA VALERIO vs. KIMCO STAFFING SERVICES, INC.; XL INSURANCE

Defendant sought reconsideration of a Findings and Award (F&A) from August 5, 2025, concerning an injury sustained by applicant Bertha Valerio on September 9, 2021. The F&A found that applicant's injury was AOE/COE, defendant failed to prove improper treatment outside the Medical Provider Network (MPN), and lien claimant Joyce Altman Interpreting, Inc. established their market rate for interpreting services. Defendant contended that medical treatment and interpreter services were unreasonable due to treatment outside the MPN and failure to adhere to MTUS/ACOEM guidelines, and that the market rate for interpreter services was not properly established. The Appeals Board denied the petition, agreeing with the WCJ that defendant failed to sustain its burden of proof on the MPN issue, the MTUS/ACOEM guideline issue was not raised at trial, and lien claimant properly established their market rate.

WCABPetition for ReconsiderationFindings and AwardMedical Provider NetworkMPNRequests for AuthorizationRFAsLien ClaimantMarket RateLabor Code Section 4600
References
Case No. ADJ8115084
Regular
Jun 02, 2014

MARY HAYWORTH vs. KCI HOLDINGS USA, INC., FIDELITY AND GUARANTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, rescinding a prior finding that the applicant failed to establish a plainly erroneous fact in an Independent Medical Review (IMR) determination. The Board found the IMR decision was based on a plainly erroneous mistake of fact because it evaluated a request for dorsal medial branch block injections as though it were a request for facet injections, which are different procedures. Consequently, the medical treatment dispute is remanded to the Administrative Director for review by a different independent review organization or reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.5Plainly Erroneous Finding of FactMedical Treatment DisputeUtilization ReviewAdministrative DirectorDorsal Medial Branch BlockFacet InjectionsMTUS Guidelines
References
Case No. ADJ2068970 (STK 0167616)
Regular
Jul 21, 2016

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

The applicant seeks reconsideration of a WCJ's decision that dismissed his appeal of an Independent Medical Review (IMR) determination regarding pain medication. The IMR found the medication medically unnecessary, but the applicant argues this was based on a plainly erroneous finding of fact regarding the applicable treatment guidelines. The Appeals Board granted reconsideration, finding the IMR determination was indeed based on a plainly erroneous interpretation of the medical treatment guidelines. Consequently, the Board rescinded the WCJ's decision and remanded the case for a new IMR by a different reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewPlainly Erroneous Finding of FactLabor Code Section 4610.6Medical Treatment GuidelineOpioid TherapyPermanent DisabilityVocational RehabilitationAdministrative Law JudgeReconsideration
References
Case No. ADJ9197803
Regular

CHRISTOPHER TORRES vs. CONTRA COSTA SCHOOLS INSURANCE GROUP, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied Christopher Torres's petition for reconsideration of an Independent Medical Review (IMR) determination. The Board found that the applicant failed to prove, by clear and convincing evidence, any of the limited grounds for appeal specified in Labor Code section 4610.6(h). Specifically, the Board agreed with the WCJ that whether the IMR reviewer correctly applied medical guidelines involves expert opinion, not a matter of ordinary knowledge. Therefore, the Board upheld the IMR decision.

WCABPetition for ReconsiderationLabor Code Section 4610.6Administrative DirectorMedical ReviewIndependent Medical Reviewer (IMR)MTUS guidelinesACOEM guidelinesClear and convincing evidencePlainly erroneous finding of fact
References
Case No. ADJ393547 (ANA 0389753)
Regular
Apr 06, 2010

TOMAS GARCIA vs. METERMAN INC, STATE COMP. INSURANCE FUND

This case involves a dispute over the authorization of an orthopedic mattress for a workers' compensation applicant. The defendant denied the request through utilization review, citing lack of supporting medical guidelines. The Appeals Board reversed the WCJ's award, finding the applicant failed to properly initiate the dispute resolution process under Labor Code section 4062(a). The matter was returned to the trial level for referral to the Agreed Medical Examiner to address the medical necessity of the mattress.

Utilization ReviewLabor Code Section 4610Labor Code Section 4062(a)Agreed Medical ExaminerOrthopedic MattressMedical Treatment DisputeReconsiderationFindings and AwardExpedited HearingWorkers' Compensation Appeals Board
References
Case No. ADJ1347643
Regular
Apr 15, 2009

EVA RODRIGUEZ vs. AMERIKLEEN, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration to address inconsistencies in the trial judge's findings regarding lien claimant Cordova Chiropractic's treatment dates. The Board found the record unclear as to which specific treatment dates were disallowed and whether Dr. Park's QME report was properly considered. Specifically, the Board noted that Dr. Park's report appeared to approve past medical care, including May 2008 treatments rejected by the trial judge, and that the trial judge's reasoning for disallowing treatment lacked clear justification. The case is returned to the trial level for further proceedings to clarify the record and ensure proper application of relevant medical guidelines.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFindings and AwardPresiding Workers' Compensation JudgeReasonable and Necessary TreatmentQualified Medical EvaluatorACOEM GuidelinesLabor Code Section 4600Senate Bill 899
References
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. ADJ8286511
Regular
May 30, 2017

HECTOR SANCHEZ BARRAGAN vs. T&T MARKETING SERVICES, INC., STATE COMPENSATION INSURANCE FUND

This case concerns the applicant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision that upheld an Independent Medical Review (IMR) denial of a Norco prescription. The applicant argued the IMR determination exceeded the Administrative Director's authority due to a plainly erroneous application of Medical Treatment Utilization Schedule (MTUS) guidelines. The WCAB denied the petition, adopting the trial judge's report which found the IMR reviewer correctly applied medical expertise to select relevant MTUS sections for chronic opioid use. The Board determined the applicant failed to provide clear and convincing evidence of erroneous MTUS application or that the IMR decision was otherwise invalid.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardIndependent Medical ReviewUtilization ReviewNorcoMedical Treatment Utilization ScheduleAdministrative DirectorLabor CodeChronic Pain Medical Treatment Guidelines
References
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