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

Case No. ADJ4523909
Regular
Mar 04, 2016

GLORIA BLACKMON vs. ABZ AUTO WRECKAGE, TRUCK INSURANCE COMPANY, FARMERS INSURANCE EXCHANGE

This case concerns an applicant's petition for reconsideration of a denial of medical treatment authorization. The Workers' Compensation Appeals Board (WCAB) denied the petition, upholding the administrative law judge's decision. The key issue was whether an untimely Independent Medical Review (IMR) determination invalidates the IMR process, thereby allowing the WCAB to decide treatment necessity. The majority found the IMR timelines to be directory, not mandatory, and thus the untimely IMR was valid and binding. A dissenting commissioner argued the IMR timelines are mandatory, and an untimely IMR should allow the WCAB to determine treatment necessity.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewSB 863Labor Code section 4610.6(h)Administrative Directormandatory vs. directorymedical treatment disputeprescription medicationsWellbutrin
References
27
Case No. ADJ10061866
Regular
Jun 20, 2016

MARK CRONIN vs. CITY OF LOS ANGELES

Here's a summary of the case for a lawyer: The Workers' Compensation Appeals Board denied reconsideration of a decision finding a late Independent Medical Review (IMR) determination valid. The Board ruled that timeframes for IMR issuance are directory, not mandatory, and a late IMR does not invalidate the determination. Therefore, the applicant cannot object to the IMR's timeliness after it has been issued. The Board followed precedent holding that untimeliness of an IMR does not invalidate it, thus an objection on that basis is waived.

Workers' Compensation Appeals BoardIndependent Medical ReviewIMRuntimely IMRreconsiderationmedical treatment disputeLabor Code section 4610.6(d)directory timeframesmandatory timeframesutilization review
References
37
Case No. ADJ9661661
Regular
Jun 30, 2016

CHRISTOPHER TYNI vs. CITY OF MONTEBELLO

This case concerns an untimely Independent Medical Review (IMR) determination regarding applicant's medical treatment. While the Board acknowledges the IMR was issued outside statutory timeframes, it clarifies that these time limits are directory, not mandatory, and do not affect the IMR's validity. Therefore, the Board affirmed the original decision that it lacks jurisdiction to decide medical treatment disputes once submitted to IMR. The case was returned to the trial level with an amended finding correcting the IMR timing calculation.

Workers' Compensation Appeals BoardIndependent Medical ReviewIMRuntimely IMRmedical treatment disputejurisdictionLabor Code section 4610.6(d)directory timeframesmandatory timeframesUtilization Review
References
1
Case No. ADJ156419
Regular
Feb 20, 2019

JOCELYN BOWEN vs. COUNTY OF SAN BERNARDINO

The Workers' Compensation Appeals Board reversed a prior Independent Medical Review (IMR) decision that denied the applicant's Norco prescription. The Board found the IMR reviewer failed to consider all submitted medical records and prior IMR determinations, leading to plainly erroneous findings of fact. Specifically, the IMR reviewer incorrectly stated there was no documentation of functional improvement with Norco, despite such documentation being present. The case is remanded for a new IMR review by a different reviewer or organization.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewPlainly Erroneous FindingsAdministrative DirectorLabor CodeMedical Treatment Utilization ScheduleNorcoPain ManagementOrthopedic Surgery
References
11
Case No. ADJ9290138
Regular
Jul 14, 2016

MATT JACOBS vs. PARSEC, INC./BUDCO; ACE USA

This case denied an applicant's petition for reconsideration of a decision upholding an Independent Medical Review (IMR) denial of knee surgery authorization. The applicant argued the IMR determination was invalid due to untimeliness, but the Board found the statutory timeframes for IMR decisions are directory, not mandatory. Therefore, a delay in the IMR decision does not invalidate it, and the applicant remains bound by the IMR's finding on the medical necessity of the proposed treatment. The Board affirmed the WCJ's decision, denying the applicant's petition for reconsideration.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code section 4610.6(h)Utilization ReviewTotal ArthroplastyTimelinessAdministrative DirectorPlainly Erroneous Finding of FactDirectory vs. MandatoryMargaris
References
4
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
0
Case No. ADJ3223915
Regular
Aug 08, 2016

Francisco Correa vs. ANDIAMO, INC., STATE COMPENSATION INSURANCE FUND

This case concerns a dispute over applicant Francisco Correa's prescription for Zanaflex. Initially, the Workers' Compensation Appeals Board (WCAB) rescinded a prior decision that invalidated Independent Medical Review (IMR) determinations, finding that IMR timeliness is directory, not mandatory. However, upon reconsideration, the WCAB recognized that the prior decision failed to address unchallenged findings that the IMRs were substantively defective. Consequently, the WCAB is now remanding the case to the Administrative Director for a new IMR, finding that the applicant's appeal of the original IMR determinations is valid.

Independent Medical ReviewIMRMedical Treatment Utilization ScheduleMTUSZanaflexLabor Code section 4610.6Stevens v. Workers' Comp. Appeals Bd.Administrative DirectorUtilization ReviewPetition for Reconsideration
References
11
Case No. ADJ1060696
Regular
Jan 14, 2016

MARIA URIBE RAMOS vs. PATTERSON FROZEN FOODS, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY

This case involves an applicant's appeal of Independent Medical Review (IMR) determinations regarding prescription medication refills for Flexeril and Norco. The Workers' Compensation Appeals Board (WCAB) granted the appeal for Flexeril, finding the initial IMR determination was issued in excess of the Administrative Director's powers due to an incomplete medical record. The WCAB affirmed the IMR determination for Norco, agreeing that the record was complete for that medication. A dissenting opinion argued that both IMR determinations for Flexeril and Norco, and an additional IMR determination for clonidine, were flawed and should have been remanded for further review.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.6(h)Plainly Erroneous Finding of FactIncomplete Medical RecordExcess of PowersRemandUtilization ReviewMedical Treatment Utilization ScheduleCompromise and Release
References
3
Case No. ADJ1313860
Regular
Mar 07, 2017

Kevin Voelker vs. D. Frey Plastering Co., State Compensation Insurance Fund

This case involves a workers' compensation applicant challenging an Independent Medical Review (IMR) determination that denied authorization for shoulder surgery. The applicant argued the IMR incorrectly applied guidelines for acromioplasty/impingement syndrome instead of guidelines for a rotator cuff tear, which was the actual condition for which surgery was requested. The Appeals Board granted reconsideration, finding the IMR's determination was based on a plainly erroneous mistake of fact readily apparent from the submitted records, not requiring expert opinion. Consequently, the Board rescinded the IMR determination and remanded the matter for a new IMR process.

Workers' Compensation Appeals BoardIndependent Medical ReviewPetition for ReconsiderationFindings and OrderPlainly Erroneous Finding of FactMedical Treatment Utilization ScheduleRequest for AuthorizationRotator Cuff TearAcromioplastyImpingement Syndrome
References
3
Case No. ADJ1 798995 (SAC 0324817)
Regular
Mar 08, 2016

Richard Hill vs. Tuttle Interior Systems, State Compensation Insurance Fund

The Workers' Compensation Appeals Board (WCAB) reversed a finding that an Independent Medical Review (IMR) determination was moot due to untimeliness. The Board held that while the Utilization Review (UR) decision expired, the subsequent IMR determination, even if issued outside statutory timeframes, remained valid. The WCAB emphasized that untimeliness is not a statutory ground to appeal an IMR decision and that IMR timeframes are directory, not mandatory. Consequently, the case was returned to the trial level, with the existing IMR decision binding unless grounds for appeal under Labor Code section 4610.6(h) are established.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization ReviewIndependent Medical ReviewLabor Code § 4610.6SB 863Medical NecessityDirectory vs. Mandatory TimeframesAdministrative DirectorMaximus Federal Services
References
31
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