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

Case No. GOL 96757
Regular
Jun 10, 2008

SA YANG LO vs. CUSTOM SENSORS & TECHNOLOGIES, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration of a prior award, upholding the application of the 2005 Permanent Disability Rating Schedule. The Board found that exceptions allowing for the 1997 Schedule did not apply, as the applicant's temporary disability indemnity extended beyond January 1, 2005, and no qualifying pre-2005 reports indicated permanent disability. Furthermore, the Board found the applicant's vocational expert's opinion regarding diminished future earning capacity unpersuasive, thus affirming the initial 9% permanent disability rating.

Workers' Compensation Appeals BoardSA Yang LoCustom Sensors & TechnologiesInc.State Compensation Insurance FundGOL 96757Opinion and Order Denying ReconsiderationFindings and AwardWorkers' Compensation Administrative Law JudgeWCJ
References
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 The Appeals Board rescinded the prior award and returned the matter for further proceedings, as the definition of "amputation" in precedent excludes internal body parts like those removed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. ADJ9546300 ADJ9103215
Regular
Apr 21, 2015

JAMES TUBBS vs. FRESNO CHAFFEE ZOO, NATIONWIDE AGRIBUSINESS INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and reversed a prior decision, finding the applicant is not entitled to a second lumbar surgery. The WCAB concluded that the applicant failed to meet the burden of proof by providing substantial medical evidence demonstrating the surgery's reasonableness and necessity, as required by Labor Code sections 5705 and 4600. While acknowledging the prior successful surgery, the WCAB found Dr. Aryan's request lacked sufficient support based on established medical treatment guidelines. The dissenting opinion argued that substantial medical evidence supported the surgery and that the defendant's delays unfairly prejudiced the applicant.

ADJ9546300ADJ9103215lumbar spine injuryDr. Francisco UnguezDr. Henry AryanRequest for Authorization (RFA)surgery authorizationL4-S1 surgeryDubon IIsubstantial medical evidence
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. ADJ2965812 (SAC 0308365)
Regular
Apr 23, 2012

CHRISTINE KRAUSE vs. STATE OF CALIFORNIA, SECRETARY FOR RESOURCES AGENCY, Legally Uninsured, Adjusted By STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded an order compelling the defendant to provide cervical spine surgery, deferring the issue pending a final report from a Spinal Surgery Second Opinion Physician (SSSOP). The SSSOP's report was delayed beyond the statutory 45-day timeframe, but the WCAB found neither party was at fault for this delay, and obtaining the SSSOP's opinion was crucial for a proper decision. The WCAB dismissed the defendant's petition for removal. A dissenting commissioner argued the defendant should be liable for the surgery due to the delayed process, citing precedent that placed the burden on the employer to ensure timely adherence to statutory procedures.

Workers' Compensation Appeals BoardPetition for ReconsiderationSpinal Surgery Second Opinion PhysicianUtilization ReviewLabor Code Section 4062(b)Industrial InjuryCervical Spine SurgeryTreating PhysicianIndustrial InjuryDeclaration of Readiness to Proceed
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. ADJ8419958
Regular
Jan 16, 2014

FELIPE RAMIREZ vs. D'ARCY & HARTY CONSTRUCTION, INC., OLD REPUBLIC GENERAL INSURANCE CORPORATION

This case involves a worker's compensation applicant, Felipe Ramirez, seeking approval for spinal surgery recommended by his treating physician, Dr. Naraghi. The defendants contested the surgery, and Utilization Review initially denied the request. The Administrative Law Judge (ALJ) awarded the surgery, finding the UR denial invalid as the reviewing doctor lacked crucial medical information. The Appeals Board denied the defendants' petition for reconsideration, affirming the ALJ's decision.

Workers' Compensation Appeals BoardPetition for ReconsiderationDenialSpinal surgeryDr. NaraghiUtilization ReviewNon-certificationDr. DeutschSandhagenLabor Code §4610
References
Case No. ADJ3409548 (RDG 0112116) ADJ2825274 (RDG 0112117)
Regular
Aug 21, 2014

Alice Swetzer vs. OFFICE MAX, OLD REPUBLIC, GALLAGHER BASSETT SERVICES

The Appeals Board rescinded the WCJ's denial of Alice Swetzer's petition to reopen, finding the medical record regarding her right sacroiliac fusion surgery was insufficiently developed. Applicant argues her industrial back and knee injuries contributed to the need for surgery, even if a fall precipitated it. The Board agreed that existing medical opinions did not fully address whether the industrial injuries exacerbated her condition or if the surgery was medically necessary to treat the industrial injury's effects. Therefore, the case is returned to the trial level for further medical evidence development on these causal links.

Compensable consequence doctrineSacroiliac fusion surgeryIndustrial injuryFurther development of medical recordQME opinionCausationPreexisting conditionAggravationMedical necessityReconsideration
References
Case No. FRE 191206
Regular
Nov 20, 2007

MARY SEPEDA vs. SEPEDA BROTHERS DAIRY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION on behalf of FREMONT INDEMNITY, in liquidation, REPUBLIC INDEMNITY

This case involves an applicant seeking reconsideration of a workers' compensation award concerning a low back injury sustained through July 13, 1995. The applicant, supported by her treating physician, argued for additional disc replacement surgery at the L4-5 level beyond the previously awarded L5-S1 spinal fusion. The Workers' Compensation Appeals Board granted reconsideration and amended the award to include the L4-5 disc replacement surgery, finding it reasonably required to cure or relieve the applicant's injury based on the treating physician's opinion.

CIGAFremont IndemnityRepublic Indemnitylow back injurypermanent disabilityfurther medical treatmentspinal surgeryL5-S1 fusionL4-5 disc replacementtreating physician
References
Case No. SAC 286368
Regular
Jan 25, 2008

DALE OLIVER vs. BRIAN WILLIAMS CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking approval for disc replacement surgery for a work-related back injury. The defendant argued the surgery is experimental per ACOEM guidelines, thus not covered. The Board denied reconsideration, finding the applicant's physician rebutted the presumption of experimental status. The Board determined the surgery is no longer experimental, citing FDA approval, and is reasonably required for the applicant's specific condition, supported by expert medical opinion.

Workers' Compensation Appeals BoardBrian Williams ConstructionState Compensation Insurance Fundindustrial injuryright anklefootelbowshoulderskneesleft lower extremity
References
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