Updated Daily

Case Law Database

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

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. 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 Therefore, the prior award granting the surgery was rescinded.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. 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 However, the Board rescinded the administrative law judge's order to return the request to UR.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. 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. 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. 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. 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

Case No. ADJ9767710

Regular

Jun 21, 2016

BRENT BAISCH vs. VIDEO ONLY, INC., LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied defendant's petition for reconsideration of an award for continued care at CareMeridian. The Administrative Law Judge found the defendant failed to conduct timely utilization review (UR) for the applicant's continued care, rendering the UR invalid. The Board agreed that the untimely UR allowed them to determine the medical treatment dispute and that continued care at CareMeridian was reasonable and necessary pending an appropriately arranged transfer. The Board affirmed the finding that the defendant failed to comply with statutory requirements for concurrent UR.

Workers Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewLabor Code Section 4610Concurrent ReviewRequest for AuthorizationFindings and AwardPetition for ReconsiderationIndustrial InjuryMedical Treatment Dispute

References

Case No. ADJ7656854 ADJ7656855

Regular

Feb 14, 2020

ANGELIQUA DIAZ vs. SOUTHERN CALIFORNIA GAS COMPANY

This case addresses whether a worker can receive penalties for delayed medical treatment when the delay stems from the utilization review (UR) process. The Board granted reconsideration, rescinding the original decision and finding that Labor Code section 4610.1 bars penalties for delays occurring during UR. Furthermore, the Board determined it lacks jurisdiction to assess the accuracy of UR decisions when those decisions are timely, deferring such disputes to the Independent Medical Review (IMR) process. Therefore, the applicant's petitions for penalties were denied.

Labor Code section 5814Utilization ReviewLabor Code section 4610.1Independent Medical ReviewPrimary Treating PhysicianWCAB jurisdictionDubon v. World RestorationInc.unreasonable delaymandatory statutory guidelines

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. 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. ADJ8484771

Regular

Nov 14, 2014

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

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. ADJ3852255 (SRO 0128541)

Regular

Dec 02, 2014

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

Utilization ReviewFindings and OrderPetition for ReconsiderationWCJDubon IIen banc decisionprocedural defectreasonable and necessarymedical treatmentepidural injection

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. ADJ6939280

Regular

Nov 08, 2018

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

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

Case No. ADJ9767710

Regular

Jun 21, 2016

BRENT BAISCH vs. VIDEO ONLY, INC., LIBERTY MUTUAL INSURANCE COMPANY

References

Case No. ADJ7656854 ADJ7656855

Regular

Feb 14, 2020

ANGELIQUA DIAZ vs. SOUTHERN CALIFORNIA GAS COMPANY

References

Showing 1-10 of 295 results

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