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

Case No. ADJ3406569 (SAC 0323378)
Regular
Jan 28, 2009

JOSEPH NOVAK vs. SIERRA PACIFIC INDUSTRIES, SIERRA PACIFIC REDDING

The Workers' Compensation Appeals Board granted reconsideration and modified the prior decision. While upholding the finding of industrial injury and the need for a dorsal column stimulator, the Board rescinded the penalty and attorney's fees previously awarded. This modification was based on the finding that the defendant's delay in providing the stimulator was not unreasonable, as it stemmed from a genuine doubt arising from utilization review. The Board also affirmed the denial of the defendant's petition to change physicians, emphasizing the importance of the doctor-patient relationship and existing medical history.

Workers' Compensation Appeals BoardJoseph NovakSierra Pacific Industriesdorsal column stimulatorUtilization Reviewunreasonable delaypenaltyattorney's feesemployer-designated physicianAdministrative Director
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. ADJ3910099 (VNO 0356154)
Regular
Nov 26, 2013

JAMES CORRELL vs. L. A. DAILY NEWS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded a prior award of 100% permanent disability. The Board found insufficient evidence for injury to the applicant's neck and ordered apportionment of psychiatric disability to non-industrial factors, as suggested by one Agreed Medical Examiner. Furthermore, the record requires development to properly rate the applicant's lumbar spine and headache-related permanent disability under the 1997 PDRS, particularly regarding pre-injury capacity. The case is returned for further proceedings and a new decision by the WCJ.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryNeck InjurySpinal InjuryHeadachesPsychiatric DisabilityApportionmentPermanent Disability
References
Case No. ADJ6857073
Regular
Jun 06, 2014

ENEIDA SOLIS vs. SUN VIEW VINEYARDS, STATE COMPENSATION INSURANCE FUND

The Appeals Board denied Rehab Solutions' petition for reconsideration, upholding the WCJ's disallowance of its lien. Rehab Solutions failed to meet its burden of proof by providing substantial medical evidence that the interferential stimulator was necessary and appropriate for the applicant. The WCJ correctly found that the lien claimant did not demonstrate the reasonable value of services exceeded the amount already paid by the defendant. Consequently, the Board found no error in disallowing the lien.

Lien claimantPetition for ReconsiderationFindings of Fact & OrderWCJsubstantial evidencemedical treatmentreasonable valueutilization reviewQualified Medical Evaluatorinterferential stimulator
References
Case No. ADJ1311571 (SAC 0331121)
Regular
Apr 23, 2010

JOSEPH BAKER vs. TINK, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration, rescinded a prior order, and returned the case for further proceedings. The dispute concerns reimbursement for an RS4i stimulator device, with the lien claimant arguing the initial utilization review denial was improper. The Board found the WCJ did not adequately address whether the RS4i device is equivalent to a TENS unit and how treatment guidelines apply to the applicant's chronic condition. Further development of the medical record is necessary to determine the reasonableness of the prescribed treatment.

RS4i stimulatorUtilization ReviewACOEM GuidelinesTENS unitchronic painacute low back painMedical Treatment Utilization Schedulelien claimantreconsiderationWCJ
References
Case No. SDO 0309691
Regular
Jan 29, 2008

TERESA ROBLES vs. FAIRFIELD RESIDENTIAL, LLC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration of a WCJ's decision that a neuromuscular stimulator provided by Advanced Rehabilitation Technologies (ART) was reasonable and necessary medical treatment. The Board found the medical evidence supporting the WCJ's decision was insufficient, specifically noting unclear reports from Dr. McClung and the absence of opinion from the agreed medical evaluator, Dr. Wieseltier. The case was returned to the trial level for further development of the record, including obtaining supplemental reports from the treating physicians.

ReconsiderationNeuromuscular stimulatorReasonable and necessaryMedical treatmentLien claimantStipulated awardPermanent disabilityAgreed medical evaluator (AME)Record developmentSupplemental reports
References
Case No. ADJ5827846
Regular
May 29, 2013

TSHEA PARTNER vs. SOUTHERN CALIFORNIA EDISON

This Workers' Compensation Appeals Board case denied reconsideration of a lien claim by Pinnacle Lien Services on behalf of Access Mediquip. The applicant received spinal stimulator implants, and the lien claimant sought payment for implantable devices. The Appeals Board adopted the judge's report, which found that the charges for the implantable devices were included in the payments made to the surgery center. The court determined that the lien claimant failed to provide sufficient evidence to prove the defendant's liability for these separately itemized devices.

Petition for ReconsiderationWorkers' Compensation Appeals BoardSouthern California EdisonPinnacle Lien ServicesAccess MediquipSpinal stimulatorImplantable devicesCPT codesAmbulatory Surgery CenterDe Anza Ambulatory Surgery Center
References
Case No. ADJ8369887
Regular
Feb 23, 2015

JERYL SUTTLE vs. SHARP HEALTHCARE, ACE AMERICAN INSURANCE, Administered By ESIS

The Workers' Compensation Appeals Board denied Jeryl Suttle's petition for reconsideration. The Board adopted the Administrative Law Judge's report, which found that the applicant's contentions were not supported by the evidence. Specifically, the removal of a bone growth stimulator for an MRI was deemed necessary for treatment evaluation, not a medical-legal exam. The IMR decision upheld the denial of this treatment, and reconsideration was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization ReviewIndependent Medical Reviewbone growth stimulatorMRIspinal surgeonmedical-legal examtreating physicianadministrative law judge
References
Case No. ADJ7390255
Regular
Jan 03, 2023

DARNELLA SCOTT STREET vs. SAN FRANCISCO BAY AREA RAPID TRANSIT DISTRICT, ATHENS ADMINISTRATORS

The Workers' Compensation Appeals Board denied reconsideration of a decision allowing a lien claim for an H-Wave machine. The applicant found more relief with the H-Wave than a TENS unit. The Agreed Medical Examiner opined that while not convinced the H-Wave was superior to other inferential stimulation units, it was superior to a TENS unit. The WCAB found the lien claimant met its burden of proof regarding the medical necessity of the H-Wave.

Workers' Compensation Appeals BoardSan Francisco Bay Area Rapid Transit DistrictAthens AdministratorsPetition for ReconsiderationWorkers' Compensation Administrative Law Judgesubstantial evidenceElectronic Waveform LabsH-WaveTENS unitinferential stimulation unit
References
Case No. ADJ2661083 (AHM 0097587) ADJ2316310 (AHM 0088976)
Regular
Oct 06, 2014

GENEEN RODRIGUEZ vs. STATEK CORPORATION, ACE USA

This case involves defendant Statek Corporation's petition for reconsideration of an award granting applicant Geneen Rodriguez a spinal cord stimulator. The Administrative Law Judge found the utilization review (UR) determination materially defective due to communication issues and the reviewer's specialty. The Appeals Board granted reconsideration, rescinded the award, and found the UR determination was not materially defective. The Board concluded that any alleged defects were not significant enough to bypass the Independent Medical Review (IMR) process.

Utilization ReviewSpinal Cord StimulatorMaterially DefectiveIndependent Medical ReviewLabor Code Section 4610Medical NecessityCompetency of ReviewerInternal MedicineTimely CommunicationDubon v. World Restoration
References
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