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

Case No. SAL 0107786
Regular
Oct 16, 2007

MOLLY KIRKPATRICK vs. DOMINICAN SANTA CRUZ HOSPITAL, PSI ADMINISTERED BY OCTAGON RISK SERVICES

This case concerns an injured worker who had cervical spine surgery involving diskectomy, vertebrectomy, decompression, and fusion. The defendant sought reconsideration of an award granting temporary disability benefits beyond the statutory 104-week limit, arguing the surgery was not an amputation. The Appeals Board rescinded the prior award and returned the matter for further proceedings, as the definition of "amputation" in precedent excludes internal body parts like those removed during spinal fusion.

Workers' Compensation Appeals BoardDominican Santa Cruz HospitalOctagon Risk ServicesMolly KirkpatrickIndustrial InjuryCervical Spine SurgeryTemporary Disability IndemnityLabor Code Section 4656(c)AmputationDiskectomy
References
Case No. ADJ1438639 (GRO 0024593) ADJ3262777 (GRO 0025366)
Regular
Sep 20, 2011

Dennis Timmons vs. CALIFORNIA MENS COLONY, STATE COMP. INS. FUND, SUBSEQUENT INJURIES BENEFITS TRUST FUND

This case concerns applicant Dennis Timmons' petition for reconsideration of a denial of Subsequent Injuries Benefits Trust Fund (SIBTF) benefits. The Appeals Board reversed a prior award, finding applicant failed to prove a pre-existing permanent partial disability from a 1991 cervical fusion surgery prior to his 2000 industrial injury. Applicant argued the fusion itself constituted a previous impairment and that SB 899's apportionment changes should apply, but the Board affirmed its decision. The Board reiterated that contemporaneous medical evidence is required for SIBTF eligibility, and that SB 899 did not alter SIBTF's established requirements.

Subsequent Injuries Benefits Trust FundSIBTFpermanent disabilitypre-existing disabilitycervical fusionApril 132000 industrial injurySB 899apportionment to causationLabor Code section 4751
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. ADJ4695633 (OXN 0133122)
Regular
Oct 14, 2013

DEBRA CHELI vs. CHICO'S; HARTFORD INSURANCE, administered by BROADSPIRE

The Workers' Compensation Appeals Board denied a petition for reconsideration, upholding the findings of the administrative law judge. The judge's decision relied heavily on the credibility of the applicant and the opinion of an agreed medical examiner who found no apportionment to prior or subsequent injuries. The Board agreed with the judge that the medical examiner's opinion was persuasive, noting that the petitioner failed to provide sufficient evidence to challenge it. Therefore, the petition for reconsideration was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationAgreed Medical ExaminerApportionmentSubstantial EvidencePermanent Total DisabilityWCJMedical ReportLumbar FusionCumulative Trauma
References
Case No. ADJ7329727
Regular
Oct 10, 2014

KRISSY KORN vs. ENTERTAINMENT PARTNERS, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

The Workers' Compensation Appeals Board denied the employer's petition for reconsideration of an award for back surgery. The Board adopted the WCJ's report, except for a comment regarding the defendant's burden of proof on MTUS compliance. The Board clarified that the applicant bears the burden of proving the reasonableness of requested treatment. The employer's argument for denying the surgery based on lack of substantial medical evidence was rejected.

WORKERS' COMPENSATION APPEALS BOARDPetition for ReconsiderationWCJ reportDubon v. World RestorationApplicant burden of proofmedical treatment utilization schedulelow backright shoulderCraft Services Personanterior lumbar interbody fusion
References
Case No. ADJ1489633 (SBR 0317521)
Regular
Dec 11, 2008

STEPHANIE ROECKER vs. MONO LAKE FOUNDATIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and affirmed an award, but amended the finding on temporary disability. The Board agreed with the defendant that the applicant was adequately compensated for temporary disability per stipulation. However, the Board upheld the use of the pre-2005 permanent disability rating schedule, finding substantial medical evidence existed prior to January 1, 2005, supporting this determination.

WCABPermanent Disability Rating ScheduleTemporary Total DisabilityFindings and AwardOrder of CommutationPost Fusion RadiculopathyIndustrial InjuryMedical TreatmentStipulationReconsideration
References
Case No. ADJ7951527
Regular
Oct 03, 2016

RONALD COYLE vs. DANE COYLE CUSTOM HOMES, INC.

The defendant sought reconsideration of an award for an applicant's industrial back injury, challenging the timeliness of the utilization review (UR) denial and the necessity of proposed spinal surgery. The Board denied reconsideration, affirming that the defendant failed to prove timely communication of the UR denial as required by law. Furthermore, substantial evidence, including reports from the treating physician and Agreed Medical Evaluator, supported the necessity of the lumbar fusion surgery. The Board found the defendant's arguments insufficient to rebut the expert medical opinions presented.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryUtilization Review (UR) DenialTimelinessFurther Medical TreatmentSpinal SurgeryLumbar FusionRequest for Authorization (RFA)
References
Case No. ADJ8103143
Regular
Dec 04, 2015

CHUONG VO vs. ZONARE MEDICAL SYSTEMS, INC., ONE BEACON INSURANCE COMPANY

This case involves a defendant seeking reconsideration of an order enforcing an Independent Medical Review (IMR) determination that authorized applicant's requested cervical surgery. The defendant argued a subsequent conflicting IMR determination, the WCJ's lack of jurisdiction, and an improper physician signature on the initial request voided the original IMR. The Appeals Board denied reconsideration, finding that a later IMR does not negate a prior one, the WCJ had jurisdiction to enforce the IMR, and the defendant waived the physician signature argument by proceeding with utilization review.

Independent Medical ReviewUtilization ReviewPetition for ReconsiderationLabor Code section 4610Labor Code section 4610.5anterior cervical decompression and fusionposterior cervical decompression and fusionmedical necessitywaived argumentsecondary treating physician
References
Case No. ADJ441410
Regular
Oct 03, 2008

HAYDEE NUNEZ vs. FAIRMONT MIRAMAR HOTEL, COMMERCE & INDUSTRY INSURANCE COMPANY

The Appeals Board denied the lien claimant's petition for reconsideration, affirming the WCJ's denial of the remaining lien balance. The Board is returning the case to the trial level to investigate potential sanctions against the lien claimant for its actions in filing the petition for reconsideration, citing alleged procedural defects and bad faith. The WCJ's original finding was that the outpatient fusion surgery was not permitted under Medicare Guidelines and the defendant paid more than the reasonable value of the services.

Workers Compensation Appeals BoardFairmont Miramar HotelCommerce & Industry Insurance CompanyAIG Domestic ClaimsOutpatient Spine & Surgery CenterLien claimantIndustrial injuryLow back injuryOutpatient fusion surgeryMedicare Guidelines
References
Case No. ADJ10443530
Regular
Apr 10, 2017

ARMANDO MATA vs. SUPERMERCADO MI TIERRA, LLC, CALIFORNIA INSURANCE COMPANY, APPLIED RISK SERVICES

The Workers' Compensation Appeals Board denied the employer's Petition for Removal but granted reconsideration for the limited purpose of deferring the issue of unreasonable delay in providing medical treatment. The Board affirmed the finding that the applicant is in need of cervical fusion surgery approved by utilization review. However, the Board ruled that the employer did not timely dispute the UR approval and therefore cannot defer payment, but the issue of unreasonable delay under Labor Code section 5814 was not properly before the Administrative Law Judge.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationFindings of FactUtilization Review (UR)Panel Qualified Medical Evaluator (QME)Cervical Fusion SurgeryIndustrial InjuryCausationUnreasonable Delay
References
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