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

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. ADJ42252 (SBR 0302367)
Regular
Jul 23, 2015

ELAINE HACKER vs. COUNTY OF SAN BERNARDINO-PUBLIC HEALTH DEPARTMENT

The Workers' Compensation Appeals Board (WCAB) reversed a prior decision by an administrative law judge (WCJ) that had remanded five Independent Medical Review (IMR) determinations for new reviews. The WCAB found that the WCJ erred in determining that the IMR reviews were invalid simply because they did not list the specific dates and authors of all reviewed medical records. The Board concluded that the IMR determinations sufficiently identified reviewed documents and that the WCJ could not substitute her own medical necessity judgment for that of the IMR. Therefore, the five IMR determinations are now considered final and binding, denying the applicant's requested medical treatments.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code section 4610.6(h)IMR Determinationsplainly erroneousmedical recordssubstantial evidencemedical necessityUtilization Reviewappeals
References
2
Case No. ADJ8063872
Regular
Nov 07, 2014

JOSE SANCHEZ vs. FOREVER 21, INC., FEDERAL INS./CHUBB SERVICES CORP.

The applicant's Petition for Reconsideration of an Independent Medical Review (IMR) determination is dismissed because it was filed improperly. The correct procedure to appeal an IMR determination is to file a "Petition Appealing Administrative Director's IMR Determination" at the trial level, not a Petition for Reconsideration with the Appeals Board. Furthermore, the applicant failed to attach the IMR determination itself to the petition, hindering any review of its merits. The Board also noted procedural deficiencies by both parties, including failure to provide State Bar numbers.

Independent Medical ReviewPetition for ReconsiderationUtilization ReviewAdministrative DirectorWorkers' Compensation Appeals BoardLabor CodeMaximusRFAWCJPetition Appealing Administrative Director's IMR Determination
References
0
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. ADJ8858239, ADJ8858240
Regular
Oct 13, 2016

ANTOINETTE MIRANDA vs. CALIFORNIA DEPARTMENT OF CORRECTIONS, legally uninsured

This case concerns the timeliness of an Independent Medical Review (IMR) determination for a left knee total arthroplasty. The WCJ found the IMR determination was late and the WCAB had jurisdiction, but denied the surgery due to insufficient evidence of medical necessity. The Appeals Board granted reconsideration, affirming the denial of treatment but clarifying that the timeframe for IMR issuance under Labor Code section 4610.6(d) is directory, not mandatory. Therefore, the late IMR determination is valid, and the applicant is bound by its decision regarding the medical necessity of the proposed surgery.

Independent Medical ReviewUtilization ReviewLabor Code Section 4610.6(d)Directory vs. Mandatory TimeframeMedical NecessityLeft Knee Total ArthroplastyWCJWCABPetition for ReconsiderationReport and Recommendation
References
4
Case No. ADJ1413052 (STK 0170134) ADJ4567871 (STK 0173675)
Regular
May 03, 2016

EPIFANIO MEDINA vs. SECOND NATURE, MID-CENTURY INSURANCE

The Workers' Compensation Appeals Board (WCAB) denied an applicant's petition for reconsideration, affirming the WCJ's decision that an appeal of an Independent Medical Review (IMR) determination was untimely. While the WCAB agreed the untimeliness finding lacked evidentiary support, the applicant failed to prove any of the five statutory grounds for appeal of an IMR determination by clear and convincing evidence. Therefore, the applicant could not overturn the IMR's denial of authorization for eight medications. Commissioner Sweeney dissented, arguing the applicant presented sufficient evidence of plainly erroneous findings of fact in the IMR determination.

WORKERS' COMPENSATION APPEALS BOARDEPIFANIO MEDINASECOND NATUREMID-CENTURY INSURANCEADJ1413052ADJ4567871Petition for ReconsiderationIndependent Medical Review (IMR)Labor Code section 4610.6(h)WCJ
References
8
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. 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. 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. ADJ3033041 (SBR 0286165)
Regular
Dec 09, 2014

MARIO MORALES, SR. vs. COUNTY OF SAN BERNARDINO

The Workers' Compensation Appeals Board (WCAB) dismissed the applicant's petition to appeal an Independent Medical Review (IMR) determination. The petition was dismissed because it failed to comply with WCAB rules regarding caption information, service of process, verification, and specificity of grounds. Specifically, the applicant did not properly identify the defendant, failed to serve all parties or the IMR Unit, and did not verify the petition or provide detailed grounds for appeal. The WCAB emphasized that appeals must strictly adhere to procedural requirements, including filing at the correct venue and allowing for a WCJ decision before appealing to the Board.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewPetition to ReopenStipulated AwardElectronic Adjudication Management SystemAdministrative DirectorWCAB Rules of Practice and ProcedureCalifornia Code of RegulationsLabor Code
References
0
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