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

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
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 Initially, the Workers' Compensation Appeals Board (WCAB) rescinded a prior decision that invalidated Independent Medical Review (IMR) determinations, finding that IMR timeliness is directory, not mandatory.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
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
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
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
Case No. ADJ4001054 (SAC 0153565)
Regular
Jul 02, 2016

MARYANN MAYFIELD-WEIGANT vs. ROSEVILLE COMMUNITY HOSPITAL, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for BEAVER INSURANCE, a subsidiary of FREMONT COMPENSATION, in liquidation

This case concerns a worker's appeal of two Independent Medical Review (IMR) denials for prescription medication and lumbar surgery. The Administrative Law Judge (ALJ) found insufficient evidence to overturn the IMR decision for medication and noted the surgery IMR was late but upheld its validity. The Workers' Compensation Appeals Board denied reconsideration, affirming the ALJ's decision. They held that the timeliness of an IMR determination is directory, not mandatory, and therefore does not invalidate the decision, citing precedent.

Independent Medical ReviewIMRPetition for ReconsiderationWorkers' Compensation Appeals BoardWCJLumbar spine injuryUtilization reviewPrescription medicine authorizationLumbar surgery authorizationPlainly erroneous
References
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
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. ADJ4092389 (SBR 0291114), ADJ4203796 (SBR 0291115), ADJ3646941 (SBR 0309645)
Regular
Jul 20, 2018

Gregory Long vs. RALPHS GROCERY COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board (WCAB) denied reconsideration of a Findings and Order that found the defendant complied with a prior Independent Medical Review (IMR) decision. The WCAB affirmed the administrative law judge's ruling that each prescription for applicant Gregory Long's opioid pain medication requires separate Utilization Review (UR) and potential IMR, despite a previous IMR approval. The Board also noted its lack of jurisdiction to hear constitutional challenges to the UR/IMR process. Applicant's claims of unequal protection and fraud were rejected, and the WCAB found no impairment to his access to medical treatment.

Workers' Compensation Appeals BoardGregory LongRalphs Grocery CompanySedgwick Claims Management ServicesPetition for ReconsiderationFindings and OrderExpedited HearingWCJIMR determinationUtilization Review (UR)
References
Case No. ADJ6552734
Regular
Apr 02, 2015

Diane Garibay-Jimenez vs. Santa Barbara Medical Foundation Clinic, Zurich American Insurance

This case concerns a denied request for left ulnar nerve decompression surgery. The Administrative Law Judge (WCJ) upheld the denial, finding the applicant failed to provide necessary Agreed Medical Examiner (AME) reports to the Independent Medical Review (IMR), making a further review unreasonable. However, the Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding the WCJ's order. The WCAB found the defendant failed to comply with Labor Code section 4610.5(l) by not providing all relevant medical records to IMR, thus invalidating the prior IMR determination. The matter was returned for a new IMR application, holding the defendant responsible for submitting complete records.

Workers' Compensation Appeals BoardDiane Garibay-JimenezSanta Barbara Medical Foundation ClinicZurich American InsuranceADJ6552734Opinion and Order Granting Petition for ReconsiderationExpedited Findings of Fact and OrderAdministrative Law JudgeIndependent Medical ReviewUtilization Review
References
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