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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
Case No. ADJ9615494
Regular
Oct 08, 2019

CARLOS SOTO TORRES vs. THE CLIFF RESTAURANT, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded an Amended Findings of Fact and Order because essential documentation regarding the timeliness of medical-legal billings and reviews was missing. Specifically, the record lacked proof of service for the provider's invoice, the defendant's initial Explanation of Review (EOR), and the subsequent second bill review. This prevented determination of whether the defendant timely objected to the bill and whether the provider timely requested a second review, necessitating further proceedings at the trial level.

Workers' Compensation Appeals BoardReconsiderationAmended Findings of Fact and OrderQualified Medical EvaluatorQMEDr. Payam MoazzazZenith Insurance CompanyStatute of LimitationsLabor Code section 4903.5Independent Bill Review
References
Case No. ADJ9531226
Regular
Dec 04, 2018

JULICES MARTINEZ vs. SUN VALLEY GROUP, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the administrative law judge's decision. The lien claimant argued that the defendant's explanations of review (EORs) were deficient and did not trigger the lien claimant's obligation to request a second review. However, the Board found that the defendant's EORs substantially complied with statutory requirements and provided sufficient guidance to the lien claimant. Because the lien claimant failed to request a second review within the statutory timeframe, their objections to the billing were deemed waived.

Workers' Compensation Appeals BoardLien ClaimantExplanation of Review (EOR)Labor Code Section 4622Medical-legal ExpensesContested ClaimPetition for ReconsiderationAdministrative Director Rule 9794Second ReviewBill Review
References
Case No. ADJ 1293553 (VNO 0460149)
Regular
May 12, 2016

CHARLES HOLDER vs. TROY CHRISTIAN dba ADVENTURE LIMOUSINE, THE HARTFORD INSURANCE COMPANY

This case concerns a billing dispute for medical treatment provided to applicant Charles Holder. The Workers' Compensation Appeals Board (WCAB) has remanded the matter for the trial judge to determine if Independent Bill Review (IBR) was properly initiated for services rendered on or after January 1, 2013. The Court of Appeal ordered this remand due to uncertainty regarding whether the defendant provided adequate explanations of review, which is a prerequisite for IBR. If IBR was not properly initiated, the WCAB retains jurisdiction over the dispute.

Workers' Compensation Appeals BoardRemandIndependent Bill ReviewExplanation of ReviewLabor Code section 4603.2Official Medical Fee ScheduleLien ClaimantJurisdictionTrial LevelFindings
References
Case No. RDG 0115958
Significant
Nov 16, 2004

Brice Sandhagen, Applicant vs. Cox & Cox Construction, Inc.; State Compensation Insurance Fund

The Appeals Board held that the utilization review time deadlines are mandatory; if a defendant fails to meet these deadlines, any utilization review report is inadmissible, and the defendant must use the AME/QME procedure as the objecting party.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Time DeadlinesAdmissibility of EvidenceMedical Treatment RecommendationACOEM GuidelinesAgreed Medical EvaluatorQualified Medical EvaluatorSection 4062
References
Case No. ADJ7803069
Regular
Mar 22, 2016

EDILBERTO CERNA ROMERO vs. STONES AND TRADITIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and reversed the judge's finding regarding a September 14, 2015 utilization review (UR) decision. The Board found this second UR decision, which sought further information on some treatments, to be timely for all requested modalities. Consequently, the Board ruled that the UR decision of September 14, 2015, was timely, and the WCJ lacked jurisdiction to review the medical necessity of the denied treatments. The Board did not disturb the WCJ's finding that the August 12, 2015 UR decision was untimely.

Utilization ReviewTimelinessLabor Code Section 4610Request for AuthorizationDWC Form RFAIndependent Medical ReviewMedical NecessityProspective ReviewConcurrent ReviewAppeals Board
References
Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
Case No. ADJ8949526, ADJ8672351
Regular
Nov 05, 2018

ALFREDO ARGUETA vs. LA BREA DINING, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied reconsideration, upholding the administrative law judge's finding that the defendant was not liable for further payment on the lien claimant's invoices. The lien claimant argued the defendant's Explanation of Review (EOR) was deficient and thus they were not obligated to pursue a second bill review. The Board found this argument inconsistent with Labor Code section 4622, which requires timely objection to denied amounts, and adopted the WCJ's report. A dissenting opinion argued that a deficient EOR negates the requirement for a second bill review.

WCABLien claimantPetition for ReconsiderationExplanation of Review (EOR)Labor Code Section 4603.3Labor Code Section 4622Second Bill ReviewWCAB Rule 10451.1Perez v. Colorama Wholesale NurseryMedical-legal billing disputes
References
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