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

Case No. ADJ3149661 (SDO 0271415)
Regular
Apr 27, 2012

Elsa Cervantes vs. COSTCO WHOLESALE CORPORATION, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board granted reconsideration to find that applicant Elsa Cervantes sustained an industrial injury to her left shoulder, overturning the WCJ's prior decision. The Board found substantial medical evidence supported that the rotator cuff tear arose from the April 27, 2000 incident, reversing the WCJ's reliance on Dr. Lane's opinion. Applicant is entitled to further medical treatment, including surgery, and continuing temporary disability benefits for the left shoulder injury. However, the Board affirmed the WCJ's decision regarding the defendant's right to control medical treatment through its Medical Provider Network, finding no contrary evidence of substantiality to overturn the credibility findings.

Workers Compensation Appeals BoardElas CervantesCostco Wholesale CorporationSedgwick Claims Management Servicesindustrial injuryneck injuryleft trapezius muscle injurypsyche injuryleft shoulder injuryMedical Provider Network (MPN)
References
Case No. ADJ6619207 ADJ6736606
Regular
May 24, 2010

ALBERTO ALVAREZ vs. AKT DEVELOPMENT CORPORATIONS, INSURANCE OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration of a decision awarding lumbar fusion surgery, finding the WCJ erred by solely relying on the *Cervantes* decision regarding timely utilization review. The Board determined that the defendant's utilization review timeliness was unclear, and the parties had agreed to an Agreed Medical Examiner (AME) to resolve the surgery dispute before *Cervantes* was issued. Furthermore, the Board held that the treating physician's recommendation for surgery must constitute substantial evidence, which was not definitively established here. Therefore, the matter was returned for further development of the record, requiring the treating physician to address the AME's concerns regarding the necessity of fusion surgery.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationJoint Findings Award and OrderIndustrial InjuryLumbar FusionUtilization ReviewCervantes v. El Aguila Food ProductsSubstantial Medical EvidenceExpedited Hearing
References
Case No. ADJ4344691 (LAO 0885639) ADJ2533065 (LAO 0885640)
Regular
May 08, 2015

MARIA CERVANTES vs. CONSOLIDATED RETIREMENT HOMES, dba ATHERTON BAPTIST HOMES, ARCH INSURANCE COMPANY

This case concerns a defendant's challenge to an order compelling payment of an Employment Development Department (EDD) lien. The defendant argued it shouldn't pay the lien as there was no determination of applicant's entitlement to temporary disability benefits when EDD payments were made. However, the Workers' Compensation Appeals Board (WCAB) affirmed the judge's order to pay the EDD lien. The Board found the defendant's petition for reconsideration flawed as it failed to address the stipulation to pay EDD signed by defense counsel. Since the defendant did not seek relief from the binding stipulation, the WCAB upheld the original order.

Workers' Compensation Appeals BoardMaria CervantesConsolidated Retirement HomesAtherton Baptist HomesArch Insurance CompanyGallagher Bassett ServicesPetition for ReconsiderationOrder to Pay Lien ClaimantEmployment Development DepartmentEDD lien
References
Case No. ADJ888182 (PAS 0004570)
Regular
Jan 20, 2009

LUCRECIA TEJEDA vs. FELLINI'S RESTAURANT, FARMERS INSURANCE

The Appeals Board rescinded the WCJ's decision denying spinal surgery and returned the case for further proceedings, finding the defendant failed to conduct mandatory Utilization Review (UR) after a treating physician recommended surgery. The Board emphasized that per *Sandhagen* and *Cervantes*, defendants must follow strict UR and objection timelines for surgical requests. The WCJ was also directed to revisit the applicant's claims for medical mileage and penalties for non-payment of bills, as these issues were improperly deferred. The case will be decided anew by the WCJ, applying current legal standards.

Workers' Compensation Appeals BoardReconsiderationSpinal SurgeryUtilization ReviewLabor Code Section 4062(b)Agreed Medical EvaluatorTreating PhysicianDepositionPermanent DisabilityMedical Mileage
References
Case No. ADJ1505960 (RDG 0127227)
Regular
Jan 05, 2010

JOSEPH RHOADS vs. WESTERN READY MIX, INC., TRAVELERS PROPERTY \& CASUALTY

The Workers' Compensation Appeals Board rescinded a prior award of spinal surgery, remanding the case for further proceedings. The Board found that the defendant's objection to the treating physician's spinal surgery recommendation failed to follow proper utilization review procedures as outlined in *Cervantes v. El Aguila Food Products, Inc.* The defendant must now adhere to the prescribed utilization review and objection timelines, starting with a new report from the treating physician. The Board expressed no final opinion on the applicant's entitlement to surgery or the attorney's fee pending the WCJ's new decision.

Workers' Compensation Appeals BoardRemovalReconsiderationFindings and AwardWorkers' Compensation JudgeIndustrial InjurySpinal SurgeryTreating PhysicianSecond Opinion PhysicianAmerican College of Occupational and Environmental Medicine Guidelines
References
Case No. ADJ1124701 (OAK 0304697)
Regular
Jan 25, 2010

GENE THOMAS vs. SLEEP TRAIN MATTRESS CENTER, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision favoring the applicant's spinal surgery, finding that proper procedural steps were not followed. The employer's utilization review (UR) had denied the surgery, but neither party followed the required second-opinion process under Labor Code section 4062(b). The WCAB returned the case to the trial level, allowing the employer ten days from receipt of the decision to object to the surgery and initiate the second-opinion process. This decision aligns with the WCAB's en banc ruling in *Cervantes*, which clarified the procedures for handling spinal surgery disputes after UR denials.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code section 4062(b)Spinal SurgerySecond OpinionCervantes v. El Aguila Food ProductsACOEM GuidelinesExperimental TreatmentEn Banc DecisionAdministrative Director Rules
References
Case No. ADJ8991440
Regular

ELSA CERVANTES vs. OPTIONS FOR YOUTH, FIREMAN'S INSURANCE COMPANY FOR AMERICAN INSURANCE COMPANY

This case involves a Petition for Removal filed by Elsa Cervantes. The Workers' Compensation Appeals Board (WCAB) reviewed the petition and the administrative law judge's report. Finding no grounds for removal, the WCAB adopted the judge's report and issued an order dismissing the petition.

Petition for RemovalWorkers' Compensation Appeals BoardDismissalWorkers' Compensation Administrative Law JudgeOptions for YouthFireman's Insurance CompanyLos Angeles District OfficeADJ8991440Marguerite SweeneyMick Dietrich
References
Case No. ADJ7433185, ADJ7605177, ADJ7632504
Regular
Dec 07, 2012

Christine Held vs. Stanislaus County Housing Authority, Permissibly Self-Insured, administered by Innovative Claims Solutions

The Board amended the original order, finding the employer waived its right to object to the applicant's spinal surgery due to a failure to timely object to the proposed treatment. However, the Board denied the applicant's request for a penalty under Labor Code section 5814 and attorney's fees under section 5814.5, as the issue of a penalty was not appropriate for an expedited hearing and there was insufficient evidence of unreasonable delay. The matter was returned to the trial level.

Workers' Compensation Appeals BoardStanislaus County Housing AuthorityInnovative Claims SolutionsChristine HeldADJ7433185ADJ7605177ADJ7632504Fresno District OfficeOpinion and Decision After ReconsiderationFindings of Fact and Order
References
Case No. ADJ6575307
Regular
Jan 21, 2011

NANCY ANDREWS vs. LAW OFFICES OF KENNETH REYNOLDS, OAK RIVER INSURANCE COMPANY

This case involves a workers' compensation applicant who sustained industrial injuries to her back and upper extremities. The defendant sought reconsideration of a prior award, arguing they were not obligated to conduct utilization review or obtain a second opinion regarding a spinal surgery recommendation from Dr. Anderson. The Appeals Board denied the petition, finding the defendant failed to timely object or initiate the required processes after Dr. Anderson recommended the same surgery previously suggested by a second-opinion physician. The Board clarified that utilization review and second opinion obligations extend to any physician's treatment recommendations, not solely the primary treating physician.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryBack InjuryUpper ExtremitiesPrimary Treating PhysicianUtilization Review (UR)Second Opinion ProcessLabor Code Section 4062
References
Case No. ADJ3699477 (OAK 0345390)
Regular
Jul 05, 2011

GARY TOMEI vs. BAY ALARM COMPANY, TRAVELERS PROPERTY AND CASUALTY INSURANCE COMPANY

This case involves an applicant seeking authorization for cervical surgery, which was denied based on the treating physician's request not being properly formatted per AD Rule 9792.6(o). The Appeals Board granted reconsideration, finding the initial denial was due to the applicant's attorney adding a notation to the physician's report instead of the physician clearly marking it as a spinal surgery authorization request. The Board rescinded the original award, deferring the cervical surgery issue and ordering an expedited second opinion from a designated orthopedic surgeon or neurosurgeon.

Workers' Compensation Appeals BoardGary TomeiBay Alarm CompanyTravelers Property and Casualty Insurance CompanyADJ3699477Opinion and Order Granting Reconsiderationcervical surgerylumbar spineAdministrative Director Rule 9792.6(o)treating physician
References
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