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Case Law Database

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

Case No. ADJ8484771

Regular

Nov 14, 2014

MIKE REIS vs. SILVAS OIL COMPANY, EMPLOYERS INSURANCE OF WAUSAU

The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration, reversing a prior decision that had found carpal tunnel surgery authorized. The Board determined that a letter from defendant's attorney did not authorize the surgery, and the subsequent utilization review (UR) was timely and not procedurally defective. As the UR was timely, any challenges to its validity must go through Independent Medical Review (IMR), which had previously determined the surgery was not medically supported. Therefore, the prior award granting the surgery was rescinded.

Workers' Compensation Appeals BoardPetition for ReconsiderationAmended OpinionSilvas Oil CompanyEmployers Insurance of WausauUtilization ReviewAgreed Medical EvaluatorCarpal Tunnel SurgeryRequest for AuthorizationIndependent Medical Review

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

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

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

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. 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

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

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. ADJ896085

Regular

Nov 07, 2014

VALERIO FLORES vs. HVOLVOLL-JOHNSON CONSTRUCTION, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY COMPANY

This case involves a workers' compensation applicant seeking authorization for analgesic medications. The applicant's physician submitted requests, which the employer's utilization reviews (URs) denied as untimely. The Administrative Law Judge found the URs untimely and ordered authorization, disallowing the employer's UR denial documents as evidence. The employer sought reconsideration, arguing the Appeals Board lacked authority over UR timeliness and medical necessity. The Board affirmed the ALJ's decision, citing precedent that the Board retains authority over untimely URs and can determine medical necessity based on evidence when URs are invalid. The employer waived their right to challenge the timeliness finding or the medical evidence by not raising these points in their petition.

Workers' Compensation Appeals BoardUtilization ReviewRequest For AuthorizationUntimelyIndependent Medical ReviewMedical NecessityFindings And AwardPetition For ReconsiderationEn Banc DecisionDubon v. World Restoration

References

Case No. ADJ3685938 (WCK 0066506)

Regular

Dec 02, 2014

EMMETT BOONE vs. DREYER'S GRAND ICE CREAM, FIREMAN'S FUND INSURANCE COMPANY

In this workers' compensation case, the Appeals Board affirmed a prior award finding defendant's utilization review (UR) denials for prescription refills invalid. The Board agreed with the WCJ that the UR denials were untimely because the defendant failed to communicate the decisions to the treating physician within the statutory 24-hour timeframe. Consequently, the Board found the UR invalid, allowing the WCAB to determine medical necessity based on substantial evidence. This decision upholds the applicant's right to ongoing prescription refills.

Workers' Compensation Appeals BoardUtilization ReviewReconsiderationFindings and AwardPrescription RefillsMedical TreatmentDefective DenialTimeliness RequirementsLabor Code § 4610Dubon v. World Restoration

References

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Updated Daily

Case Law Database

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

Case No. ADJ8484771

Regular

Nov 14, 2014

MIKE REIS vs. SILVAS OIL COMPANY, EMPLOYERS INSURANCE OF WAUSAU

References

Case No. ADJ630145 (OXN 0147327)

Regular

Jan 15, 2015

GREGORY NILSEN vs. VISTA FORD, PACIFIC COMPENSATION INSURANCE COMPANY

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

References

Case No. ADJ4274323 (ANA 0387677); ADJ1601669 (ANA 0388466)

En Banc

Oct 06, 2014

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

UTILIZATION REVIEWINDEPENDENT MEDICAL REVIEWWCABTIMELINESSMEDICAL NECESSITYLABOR CODE SECTION 4610.5SB 863ADMINISTRATIVE LAW JUDGESUBSTANTIAL MEDICAL EVIDENCEMEDICAL TREATMENT REQUEST

References

Case No. ADJ4274323, ADJ1601669

Significant

Oct 06, 2014

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

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

Utilization ReviewPetition for ReconsiderationDefective URSubstantial Medical EvidenceAgreed Medical EvaluatorIndependent Medical ReviewMedical NecessityArthroscopic Knee SurgeryDubon IDubon II

References

Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)

En Banc

May 22, 2014

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

Utilization ReviewIndependent Medical ReviewProcedural DefectsTimelinessMedical NecessityInvalid URLegal DisputesJurisdictionSubstantial Medical EvidenceBurden of Proof

References

Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)

Significant

May 22, 2014

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

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewProcedural DefectsMedical NecessitySB 863Labor Code Section 4610.5TimelinessInvalid URSubstantial Medical Evidence

References

Case No. ADJ9460638

Regular

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

Utilization ReviewMaterial DefectDubon IDubon IIPetition for ReconsiderationFindings & OrderRescindedAdministrative Law JudgeAppeals BoardEn Banc Decision

References

Case No. ADJ896085

Regular

Nov 07, 2014

VALERIO FLORES vs. HVOLVOLL-JOHNSON CONSTRUCTION, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY COMPANY

References

Case No. ADJ3685938 (WCK 0066506)

Regular

Dec 02, 2014

EMMETT BOONE vs. DREYER'S GRAND ICE CREAM, FIREMAN'S FUND INSURANCE COMPANY

References

Showing 1-10 of 152 results

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