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Case Law Database

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

Case No. ADJ6444600
Regular
Jan 22, 2020

PAUL AGUILAR vs. CITY OF LOS ANGELES

This case involved a dispute over the timeliness of a utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, finding the original WCJ erred by concluding the UR denial was untimely solely due to lack of telephone/fax communication. While the WCAB agreed the UR denial was untimely because it wasn't communicated to the physician as required by law, it found the record incomplete regarding the medical necessity of the treatment. Therefore, the WCAB rescinded the order authorizing treatment and returned the matter to the WCJ for further proceedings to determine medical necessity.

Utilization ReviewRequest for AuthorizationTimelinessCommunicationProspective TreatmentLabor Code Section 4610Administrative Director RuleBodam v. San Bernardino CountyMedical NecessitySubstantial Evidence
References
9
Case No. MISSING
Regular Panel Decision

Brynien v. Governor's Office of Employee Relations

This case is an appeal of a Supreme Court judgment that dismissed petitioner’s applications to review denials of out-of-title work grievances. The petitioner, representing five state employees at the Office of Mental Health (OMH), alleged that employees were improperly assigned duties of a Treatment Team Leader, a higher-grade position, violating their collective bargaining agreement and Civil Service Law § 61 (2). OMH and the Governor’s Office of Employee Relations (GOER) denied the grievances, finding the duties appropriate to the employees' titles. The Appellate Division affirmed the Supreme Court's decision, holding that GOER's determination was rational. The court found that the assigned duties were a reasonable extension of the employees' in-title duties and that the employees did not meet the minimum requirements for the higher-grade Treatment Team Leader position.

Out-of-title workGrievanceCivil Service LawCollective Bargaining AgreementEmployee ClassificationJob DutiesSupervisory DutiesRational Basis ReviewAdministrative LawJudicial Review
References
5
Case No. ADJ10084576
Regular
Oct 06, 2016

ROSE SMITH vs. MEGGITT SENSING SYSTEMS PLC, THE HARTFORD

This case involves Rose Smith's workers' compensation claim where the defendant, Meggit Sensing Systems and its insurer, The Hartford, seek reconsideration of an order allowing Smith to obtain medical treatment outside their Medical Provider Network (MPN). The Appeals Board denied the petition, affirming the WCJ's finding that the defendant's failure to authorize a requested third medical opinion constituted a denial of care. This denial entitled the applicant to seek treatment outside the MPN at the defendant's expense. The defendant argued the request was procedurally deficient and not a request for treatment, but the Board found the failure to respond to the RFA for a third opinion, in context, was a failure to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Request for Authorization (RFA)Petition for ReconsiderationDenial of Medical TreatmentThird Medical OpinionUtilization Review (UR)Primary Treating PhysicianCumulative TraumaLoss of Control
References
3
Case No. ADJ3854591 (VNO 0264467)
Regular
Jan 07, 2020

ANDRZEJ WASOWICZ vs. J.L. FISHER, INC., STATE COMPENSATION INSURANCE FUND

This case concerns the timeliness of a Utilization Review (UR) denial for requested medical treatment. The applicant argued the UR denial was untimely because it was issued on the 15th calendar day, exceeding the 14-day statutory limit under Labor Code section 4610(i)(1). The Appeals Board granted reconsideration, rescinding the prior decision that found the UR timely. The Board determined the UR denial was indeed untimely and remanded the case for a new decision on the medical necessity of the treatment.

Utilization ReviewRequest for Authorizationtimelinesscalendar daysworking daysjurisdictionmedical necessityLabor CodeFindings of FactPetition for Reconsideration
References
3
Case No. ADJ1140810 (OAK 0206395)
Regular
Jul 22, 2009

FRANCISCA KOUMARIANOS vs. HADCO/ZYCON CORPORATION, ALLIANZ INSURANCE COMPANY

This case involves a dispute over attorney's fees awarded for defending an applicant's right to continuing medical treatment. The defendant sought reconsideration, arguing that Labor Code section 4607 only allows fees when an applicant *resists an attempt to terminate* an existing award, not when they challenge an informal denial of specific treatment. The Appeals Board granted reconsideration, citing *Smith v. Workers' Comp. Appeals Bd.*, which clarified that section 4607 does not permit fees for challenging a denial of specific treatment requests. Consequently, the Board rescinded the award of attorney's fees.

Workers' Compensation Appeals BoardReconsiderationAttorney's FeesLabor Code Section 4607Continuing Medical TreatmentAwardPetition to EnforceInformal DenialUtilization ReviewAgreed Medical Examiner
References
2
Case No. ADJ6507434
Regular
Jun 07, 2013

GABINO DANIEL MARTINEZ MONTES vs. MURRAY'S IRON WORKS, COMPWEST INSURANCE COMPANY

This case involves a lien claimant, Frontline Medical Associates, seeking reconsideration of the denial of their lien for medical treatment provided to an applicant, Gabino Daniel Martinez Montes. The lien was denied because the claimant failed to prove membership in the defendant's Medical Provider Network (MPN) or demonstrate the necessity of treatment for denied body parts. The Appeals Board adopted the WCJ's report, which found the lien claimant's evidence inadmissible due to non-disclosure and upheld the denial of reconsideration. The claimant also failed to establish that treatment for denied body parts was medically necessary or that the MPN process was properly bypassed.

Workers' Compensation Appeals BoardPetition for ReconsiderationWorkers' Compensation Administrative Law JudgeFrontline Medical AssociatesLien ClaimantMedical Provider Network (MPN)Pre-Trial Conference StatementAdmissible EvidenceDue ProcessLabor Code Section 4062
References
2
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
5
Case No. ADJ9917212
Regular
Mar 17, 2016

MICHAEL GREEN vs. ELLE PLACEMENT dba GOLDEN GATE STAFFING, LUMBERMEN'S UNDERWRITING ALLIANCE

This case concerns the timeliness of a defendant's utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) rescinded the initial decision awarding treatment, finding the defendant's UR denial was timely made and served within the five-business-day window. The key issue was whether a UR denial sent via facsimile after 5:30 p.m. on the fifth business day was valid. The Board concluded the UR decision was timely made and communicated within 24 hours of its making, rendering it valid and requiring disputes to go through the Independent Medical Review (IMR) process.

Utilization ReviewRequest for AuthorizationIndependent Medical ReviewWCJBusiness DayFacsimile Date StampAdministrative DirectorMedical TreatmentSpinal SurgeryArthroplasty
References
4
Case No. ADJ693974 (OAK 0242212)
Regular
Apr 26, 2019

Glory Shreeve vs. Village Shops/ Ethan Allen Carriage House, Superior National Insurance Company, BROADSPIRE, California Insurance Guarantee Association

In this Workers' Compensation Appeals Board case, applicant Glory Shreeve sought authorization for medical treatment, which was denied by the defendant's Utilization Review (UR) provider. Applicant argued the UR denials were untimely because requests for additional information were not made by a licensed physician, thus invalidating the delays and granting the Board jurisdiction over medical necessity. The Board affirmed the Administrative Law Judge's decision, finding that the UR provider's requests for additional information did not violate Labor Code Section 4610(e) and that the denials were issued within the extended timeframes permitted by DWC Rule 9792.9.1. Consequently, the Board held it lacked jurisdiction to determine the reasonableness and necessity of the requested medical treatment due to the timely UR denials.

Utilization ReviewRequest for AuthorizationLabor Code section 4610(e)DWC Rule 9792.9.1TimelinessJurisdictionMedical NecessityCalifornia Insurance Guarantee Association (CIGA)Petition for ReconsiderationAdministrative Law Judge (WCJ)
References
2
Case No. CV-24-2041
Regular Panel Decision
Jan 15, 2026

In the Matter of the Claim of Wendy Wagner

Wendy Wagner sustained work-related injuries in 1977, eventually classified with a permanent total disability. After denials of medication requests in 2022-2023, she sought a medical exemption from the Medical Treatment Guidelines and Drug Formulary. A Workers' Compensation Law Judge (WCLJ) denied her request, stating a 33-year-old agreement for treatment by a non-coded physician was outside Board jurisdiction. The Workers' Compensation Board affirmed this decision, finding no authority to compel the carrier to pay for non-coded medical providers and that other issues were not ripe. Wagner's subsequent application for reconsideration and/or full Board review was denied. The Appellate Division affirmed the denial of reconsideration, limiting its inquiry to whether the Board's denial was arbitrary and capricious or an abuse of discretion, finding no such abuse. The court also noted that many issues raised were not properly presented to the Board initially.

Workers' Compensation ClaimPermanent Total DisabilityMedical Treatment Guidelines ExemptionDrug Formulary ApplicationReconsideration DenialFull Board ReviewAppellate DivisionJurisdiction DisputeNon-coded Physician PaymentPrior Agreement Validity
References
14
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