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

Case No. ADJ8833224
Regular
Feb 21, 2017

JOHN WEIMER vs. HILLYARD, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board found that an incomplete Request for Authorization (RFA) with an incorrect claim number was submitted on September 19, 2016. Despite the error, the RFA successfully identified the employee and triggered the defendant's duty to conduct utilization review on that date. Consequently, the defendant's utilization review denial on September 29, 2016, was deemed untimely, invalidating the denial. The case was returned for further proceedings to determine the necessity of the requested medical treatment.

DWC RFAUtilization ReviewTimelinessClaim NumberIncomplete RequestMedical TreatmentReconsiderationAdministrative Director RuleTreating PhysicianClaims Adjuster
References
1
Case No. ADJ9128603
Regular
Sep 17, 2018

GAYLYNN DEWEY vs. OBJECT GEOMETRIES, INC., ONE BEACON INSURANCE GROUP

The Workers' Compensation Appeals Board (WCAB) rescinded a prior award of 24/7 home health care for six months and returned the case for further proceedings. The WCAB found the record incomplete regarding the justification for a new Request for Authorization (RFA) for home health care, given a prior Independent Medical Review (IMR) had authorized it indefinitely. The WCAB will require the trial judge to determine why the new RFA was issued, whether applicant's condition changed, and if the defendant properly terminated services under the principles of *Patterson v. The Oaks Farm*.

Workers Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewHome Health CarePost-Concussion SyndromeConversion DisorderActivities of Daily LivingRequest for AuthorizationFindings and AwardPatterson v. the Oaks Farm
References
7
Case No. ADJ9712319
Regular
Jun 20, 2025

ELEANOR DIAZ NEVAREZ vs. ELK GROVE UNIFIED SCHOOL DISTRICT, SCHOOLS INSURANCE AUTHORITY

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by defendant Elk Grove Unified School District. The Board affirmed the WCJ's decision that the utilization review (UR) was untimely and procedurally defective, specifically regarding a Request for Authorization (RFA) for an H-Wave device. The defendant had argued the RFA was incomplete, but the Board found it procedurally complete, thus triggering UR obligations. The Board concluded that the defendant's failure to issue a timely conditional denial, as required by regulations, rendered the UR invalid and untimely. Additionally, the Board confirmed its decision was issued in compliance with the 60-day timeframe stipulated by Labor Code section 5909.

WCABPetition for ReconsiderationLabor Code section 5909TransmissionElectronic Adjudication Management SystemEAMSReport and RecommendationUtilization ReviewURRequest for Authorization
References
7
Case No. ADJ10289629
Regular
Oct 19, 2017

Timothy Kirby vs. Contra Costa Water District

This case involves a clerical error where the defendant's reply brief was incomplete due to a missing second page. The Workers' Compensation Appeals Board (WCAB) initially did not consider the incomplete brief. Upon receiving the complete brief and an explanation of the error, the WCAB, exercising its discretion to correct clerical errors for due process, accepted the defendant's reply. The WCAB affirmed its prior decision, but amended the original opinion to delete the footnote referencing the incomplete brief and include the defendant's reply.

WORKERS' COMPENSATION APPEALS BOARDAMENDED OPINION AND DECISION AFTER RECONSIDERATIONPetition For Leave to File a Replyclerical errordue process rightscorrect clerical errorsconsider evidenceconsider pleadingsWCAB Rule 10848supplemental response
References
2
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
6
Case No. MISSING
Regular Panel Decision

Gorzynski v. Jetblue Airways Corp.

Plaintiff, a former employee of JetBlue Airways Corporation, initiated an employment discrimination lawsuit citing age and gender discrimination and retaliation. She moved to use an incomplete deposition transcript of Lee Gojmerae, a former co-worker, at trial, a request opposed by the Defendant. The court found that the Defendant had waived objections to the transcript's completeness by failing to promptly file a motion to suppress. Concluding that Ms. Gojmerae's testimony was highly probative and the Defendant had not demonstrated prejudice, the court granted the Plaintiff's motion. This decision allows the use of the incomplete deposition testimony, with potential jury instructions regarding its incompleteness and the possibility for Ms. Gojmerae to testify via contemporaneous transmission.

Employment DiscriminationAge DiscriminationGender DiscriminationRetaliationDeposition TestimonyAdmissibility of EvidenceMotion in LimineFederal Rules of Civil ProcedureWaiver of ObjectionRule of Completeness
References
7
Case No. ADJ4677464
Regular
Aug 01, 2017

William Moss vs. State of California Department of Corrections

This case concerns the defendant's failure to conduct timely Utilization Review (UR) on an April 2016 Request For Authorization (RFA) for the medication Enbrel. The Board denied the defendant's petition for reconsideration, upholding the WCJ's finding that the defendant's prior, invalid UR attempt in November 2015 did not relieve them of their obligation. Because no timely UR was performed on the valid RFA, the WCAB has authority to determine the medical necessity of Enbrel. The WCJ's award of Enbrel is supported by substantial evidence.

Utilization ReviewRequest For AuthorizationEnbrelSupplemental Findings And AwardWCABLabor Code section 4610(g)(6)medical treatmentrheumatoid arthritisparole agentPrimary Treating Physician's Progress Report
References
3
Case No. ADJ9884089
Regular
Feb 03, 2017

Ray Bonilla vs. San Diego Personnel and Employment DBA Good People Employment Services, Zurich American Insurance Company

This case involves a dispute over whether a Medical Provider Network (MPN) physician's recommended treatment requires Utilization Review (UR) before authorization. The Appeals Board rescinded the prior award, holding that MPN second opinion physician recommendations are not exempt from UR. The Board clarified that while MPN dispute resolution exists, it does not preclude the insurer's right to UR. However, the matter was returned for further proceedings to determine if a proper Request for Authorization (RFA) was submitted, as an improperly submitted RFA would relieve the insurer of its UR obligation.

Workers' Compensation Appeals BoardMedical Provider NetworkUtilization ReviewRequest for AuthorizationMPN Second OpinionDWC Form RFAMedical Treatment Utilization ScheduleAdministrative Director's RuleLabor Code Section 4610Independent Medical Review
References
2
Case No. ADJ10614264
Regular
Aug 30, 2017

ELIZABETH MARTINEZ vs. UVP LLC, BERKLEY REGIONAL INSURANCE COMPANY

This case concerns an applicant's petition for reconsideration of a finding denying temporary disability benefits. The Workers' Compensation Appeals Board granted reconsideration, finding that the prior decision was based on an incomplete review of medical evidence, specifically the PQME's report which referenced an incomplete operative report and contradicted applicant's testimony. The Board deferred the issue of temporary disability to allow for further development of the record at the trial level. A dissenting opinion argued that the applicant failed to meet her burden of proof and should instead pursue a petition to reopen if new evidence emerges.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of FactPanel Qualified Medical ExaminerTemporary DisabilitySubstantial Medical EvidenceMedical ReportOperative ReportPrimary Treating PhysicianDevelop the Record
References
4
Case No. ADJ8917716
Regular
May 03, 2016

INGA CZECH vs. BANK OF AMERICA, ACE AMERICAN INSURANCE COMPANY

Defendant Bank of America sought reconsideration of an award for medical treatment, arguing the Request for Authorization (RFA) was improperly served on their attorney, not the adjuster, thus not triggering utilization review timelines. The Workers' Compensation Appeals Board denied reconsideration, affirming that the applicant's physician's requested treatment was reasonable. The Board held that when an attorney receives an RFA and the defense has objected to its receipt, the attorney has a duty to transmit it to the claims administrator to fulfill the duty of good faith investigation. Therefore, the defendant's failure to process the treatment request after receiving it through their attorney resulted in liability for the awarded medical care.

Workers Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Request for Authorization (RFA)Declaration of Readiness to Proceed (DOR)Expedited HearingAdministrative Law Judge (WCJ)Agency LawAttorney NegligenceGood Faith Investigation
References
7
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