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

Case No. ADJ9460638
Regular

DAVID HAMALIAN vs. HANSEL FORD, SECURITY NATIONAL INSURANCE CO.

The Workers' Compensation Appeals Board granted the defendant's Petition for Reconsideration regarding a WCJ's order that rescinded a prior finding of no material defect in the defendant's Utilization Review (UR). This decision was based on a subsequent en banc ruling, *Dubon II*, which held that UR decisions are invalid only if untimely. Consequently, the Board rescinded the WCJ's Amended Findings & Order and remanded the case for further proceedings and a new decision consistent with *Dubon II*. The prior finding that the UR was not materially defective was rescinded, and the matter will be reheard to determine the UR's timeliness and applicant's need for surgery.

Utilization ReviewMaterial DefectDubon IDubon IIPetition for ReconsiderationFindings & OrderRescindedAdministrative Law JudgeAppeals BoardEn Banc Decision
References
Case No. ADJ652088 (VNO 0535069) ADJ247491 (VNO 0535058) ADJ7902978
Regular
Nov 17, 2014

NORMA JOVEL vs. SISTERS OF THE HOLY NAMES dba RAMONA CONVENT SECONDARY SCHOOL, UNITED STATES FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, affirming the finding that the defendant's utilization review (UR) decision denying knee surgery was defective due to missing documentation. However, the Board rescinded the administrative law judge's order to return the request to UR. Instead, the Board awarded the requested knee surgery and related treatment, finding substantial medical evidence in the record supported its medical necessity. This decision was based on subsequent case law that allows the Board to decide medical necessity when UR is defective.

Utilization ReviewPetition for ReconsiderationDefective URSubstantial Medical EvidenceAgreed Medical EvaluatorIndependent Medical ReviewMedical NecessityArthroscopic Knee SurgeryDubon IDubon II
References
Case No. ADJ 1390531 (LBO 0388008)
Regular
Apr 11, 2018

SARITA JANE BISSETT-GARCIA vs. PEACE AND JOY CENTER, VIRGINIA SURETY COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding a prior finding that the defendant's utilization review (UR) process was untimely. The WCAB found that the UR denial for home care assistance was issued within the statutory five business days, despite an alleged deficiency in the initial denial letter. Consequently, the WCAB determined it lacked jurisdiction to review the medical necessity of the requested treatment, as only timely UR decisions are subject to WCAB review.

Workers' Compensation Appeals Boardutilization reviewadministrative law judgereconsiderationcompromise and release agreementmedical treatmentLabor Code section 4610Administrative Director Rule 9792.9.1primary treating physicianindependent medical review
References
Case No. ADJ971954 (OAK 0113623)
Regular
Dec 19, 2014

LEO VIGIL vs. MILAN'S SMOKED MEATS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and affirmed the finding that the defendant's utilization review (UR) denials were untimely served, rendering them invalid. As a result, the Board found the requested medications, Norco and Pennsaid, to be reasonably necessary based on substantial medical evidence from the applicant's physician. However, the Board limited Norco refills to five, acknowledging that ongoing opioid use requires periodic review, unlike the nurse case manager services in a prior case. The case was returned to the trial level for further proceedings.

Utilization ReviewRequest for AuthorizationNorcoPennsaidTimelinessServiceInvalid URMedical NecessityDubon IDubon II
References
Case No. ADJ3852255 (SRO 0128541)
Regular
Dec 02, 2014

DENISE SITTON vs. LOK GROUP OF COMPANIES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior order finding the employer's Utilization Review (UR) decisions procedurally defective, despite being timely. The WCAB rescinded the prior order based on its subsequent en banc decision in *Dubon v. World Restoration, Inc.*, which established that only untimely UR decisions are invalid. The case is returned to the WCJ for further proceedings and a new decision consistent with the *Dubon II* ruling.

Utilization ReviewFindings and OrderPetition for ReconsiderationWCJDubon IIen banc decisionprocedural defectreasonable and necessarymedical treatmentepidural injection
References
Case No. ADJ2172104 (SAC 0326562)
Regular
Jan 15, 2015

THOMAS MEEKER vs. OREGON PACIFIC BUILDING PRODUCTS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT COMPENSATION INSURANCE COMPANY

This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in *Dubon II*, the Appeals Board reversed this finding. The Board ruled that under *Dubon II*, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.

Utilization ReviewRequest for AuthorizationProvigilDubon IIIndustrial InjuryPermanent DisabilityFuture Medical TreatmentPetition for ReconsiderationAdministrative Law JudgeWorkers' Compensation Appeals Board
References
Case No. ADJ8039057
Regular
Jan 07, 2014

LAURIE CARRICO vs. LAW OFFICES OF STEPHEN BELGUM, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior finding that the defendant's utilization review (UR) was defective regarding the applicant's shoulder surgery. The WCAB clarified its jurisdiction, stating it can only determine UR timeliness. All other disputes regarding the UR decision, including its compliance with Labor Code section 4610, must be resolved through Independent Medical Review (IMR). Therefore, the case was returned to the trial level to complete the IMR process.

Workers' Compensation Appeals BoardLaurie CarricoLaw Offices of Stephen BelgumState Compensation Insurance FundADJ8039057San BernardinoOpinion and Decision After ReconsiderationFindings and Awardindustrial injuryshoulders
References
Case No. ADJ7410410
Regular
Oct 29, 2014

MARTHA REYES vs. TARGET, INC.

The Workers' Compensation Appeals Board denied Martha Reyes' petition for reconsideration. While a utilization review (UR) decision should be signed, failure to do so does not invalidate it, per *Dubon II*. The applicant's recourse was to request Independent Medical Review (IMR), which she did. Therefore, the prior UR decision remained valid for 12 months, rendering the timeliness of the employer's denial of a subsequent request for authorization immaterial.

Utilization ReviewIndependent Medical ReviewDubon IILabor Code Section 4610Request for AuthorizationTimelinessPetition for ReconsiderationWCABEn Banc DecisionClaims Administrator
References
Case No. ADJ6939280
Regular
Nov 08, 2018

ROBIN GONZALEZ vs. FIRST PRESBYTERIAN CHURCH OF SANTA BARBARA, STATE COMPENSATION INSURANCE FUND

This case concerns applicant Robin Gonzalez's claim for ongoing home health care services following a spinal injury. The employer's insurer denied these services via a timely Utilization Review (UR) based on the Medical Treatment Utilization Schedule (MTUS). The Workers' Compensation Appeals Board (WCAB) affirmed the trial judge's decision, holding that the WCAB lacks jurisdiction to review the UR denial because the process was timely and the dispute over medical necessity must be resolved through the Independent Medical Review (IMR) process, as established in Dubon II. Applicant's treating physician can submit a new request if medically necessary, as the prior UR denial is effective for 12 months.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewMedical Treatment Utilization ScheduleJurisdictionHome Health CarePermanent DisabilityPetition to ReopenFailed Back SyndromeDubon II
References
Case No. ADJ630145 (OXN 0147327)
Regular
Jan 15, 2015

GREGORY NILSEN vs. VISTA FORD, PACIFIC COMPENSATION INSURANCE COMPANY

This case concerns an applicant's claim for Lidoderm patches as medical treatment. The employer sought reconsideration of an administrative law judge's award, arguing that a prior Independent Medical Review (IMR) decision should have prevented the award and that the matter should be remanded. The Appeals Board, applying its subsequent en banc decision in *Dubon II*, affirmed the original award. However, the Board amended the award to defer issues related to the applicant's appeal of the IMR decision and the award of Lidoderm patches.

WCABPetition for ReconsiderationFindings and AwardIndependent Medical ReviewIMRDubon v. World RestorationLidoderm patchestreating physicianLabor Code section 4610.6(i)Administrative Director
References
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