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

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 The WCAB rescinded the prior order based on its subsequent en banc decision in *Dubon v. World Restoration, Inc.*, which established that only untimely UR decisions are invalid.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
1
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Workers' Compensation Appeals Board granted the defendant's Petition for Reconsideration regarding a WCJ's order that rescinded a prior finding of no material defect in the defendant's Utilization Review (UR).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 Consequently, the Board rescinded the WCJ's Amended Findings & Order and remanded the case for further proceedings and a new decision consistent with *Dubon II*. The prior finding that the UR was not materially defective was rescinded, and the matter will be reheard to determine the UR's timeliness and applicant's need for surgery.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
3
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
14
Case No. ADJ4274323 (ANA 0387677) - MF ADJ1601669 (ANA 0388466)
Regular
Dec 16, 2013

JOSE DUBON vs. WORLD RESTORATION, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of an administrative law judge's (WCJ) decision and dismissed the applicant's petition for removal. The WCJ had previously ruled that the WCAB lacked jurisdiction to decide on the necessity of back surgery due to procedural defects in the employer's utilization review denial, deferring such issues to the Independent Medical Review (IMR) process. The WCAB found the WCJ's order to be a final decision and granted reconsideration to thoroughly review the factual and legal aspects of the case. This reconsideration is for the purpose of issuing a just and reasoned decision after further proceedings.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalAdministrative Law JudgeUtilization ReviewIndependent Medical ReviewProcedural DefectsTreating PhysicianMedically NecessaryFinal Order
References
3
Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)
En Banc
Feb 27, 2014

JOSE DUBON vs. WORLD RESTORATION, INC.; STATE COMPENSATION INSURANCE FUND

The WCAB holds that it has jurisdiction over disputes regarding the procedural validity and timeliness of utilization review (UR) decisions, while Independent Medical Review (IMR) is solely for resolving medical necessity. A UR decision with material procedural defects is invalid, and in such cases, the WCAB, not IMR, will determine the medical necessity of the treatment.

Utilization ReviewIndependent Medical ReviewEn Banc DecisionWCAB JurisdictionProcedural DefectsMedical NecessityLabor Code Section 4610Substantial Medical EvidenceMaterial Procedural DefectsInvalid UR Decision
References
17
Case No. ADJ4274323, ADJ1601669
Significant
Oct 06, 2014

Jose Dubon vs. World Restoration, Inc., State Compensation Insurance Fund

This en banc decision holds that a utilization review (UR) decision is invalid and not subject to independent medical review (IMR) only if it is untimely. Timeliness disputes are resolved by the WCAB, while all other disputes about a UR decision must be resolved by IMR.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewTimelinessMedical NecessityLabor Code Section 4610Labor Code Section 4610.5Senate Bill 863En Banc DecisionAdministrative Director
References
37
Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)
Significant
May 22, 2014

Jose Dubon vs. World Restoration, Inc., and State Compensation Insurance Fund

The Appeals Board granted the defendant's petition for reconsideration of a prior en banc decision to further study the legal and factual issues surrounding whether disputes over utilization review (UR) timeliness and procedural defects fall under the jurisdiction of the WCAB or the independent medical review (IMR) process.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewProcedural DefectsMedical NecessitySB 863Labor Code Section 4610.5TimelinessInvalid URSubstantial Medical Evidence
References
3
Case No. ADJ4274323 (ANA 0387677); ADJ1601669 (ANA 0388466)
En Banc
Oct 06, 2014

Jose Dubon vs. World Restoration, Inc.; State Compensation Insurance Fund

The Workers' Compensation Appeals Board holds that a utilization review (UR) decision is invalid and not subject to independent medical review (IMR) only if it is untimely. All other disputes regarding a UR decision must be resolved by IMR, and legal issues about timeliness must be resolved by the WCAB.

UTILIZATION REVIEWINDEPENDENT MEDICAL REVIEWWCABTIMELINESSMEDICAL NECESSITYLABOR CODE SECTION 4610.5SB 863ADMINISTRATIVE LAW JUDGESUBSTANTIAL MEDICAL EVIDENCEMEDICAL TREATMENT REQUEST
References
18
Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)
En Banc
May 22, 2014

Jose Dubon vs. World Restoration, Inc.; State Compensation Insurance Fund

The Appeals Board granted the defendant's petition for reconsideration of a prior en banc decision to further study the legal and factual issues concerning Utilization Review (UR) and Independent Medical Review (IMR) disputes. The prior decision remains in effect pending a new one.

Utilization ReviewIndependent Medical ReviewProcedural DefectsTimelinessMedical NecessityInvalid URLegal DisputesJurisdictionSubstantial Medical EvidenceBurden of Proof
References
3
Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)
Significant
Feb 27, 2014

Jose Dubon, Applicant vs. World Restoration, Inc. and State Compensation Insurance Fund

The Appeals Board held that disputes over the timeliness and procedural compliance of utilization review (UR) are legal issues for the WCAB to decide, not matters for independent medical review (IMR). A UR decision is invalid if it has material procedural defects, such as failing to review adequate medical records.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewProcedural DefectsMedical NecessityEn Banc DecisionAdministrative Director's RulesSubstantial Medical EvidenceTimelinessMaterial Procedural Defects
References
16
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