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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
Case No. ADJ9615494
Regular
Oct 08, 2019

CARLOS SOTO TORRES vs. THE CLIFF RESTAURANT, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded an Amended Findings of Fact and Order because essential documentation regarding the timeliness of medical-legal billings and reviews was missing. Specifically, the record lacked proof of service for the provider's invoice, the defendant's initial Explanation of Review (EOR), and the subsequent second bill review. This prevented determination of whether the defendant timely objected to the bill and whether the provider timely requested a second review, necessitating further proceedings at the trial level.

Workers' Compensation Appeals BoardReconsiderationAmended Findings of Fact and OrderQualified Medical EvaluatorQMEDr. Payam MoazzazZenith Insurance CompanyStatute of LimitationsLabor Code section 4903.5Independent Bill Review
References
Case No. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
Case No. ADJ2498525 (ANA 0409397)
Regular
Oct 05, 2016

JUVENAL RAMIREZ vs. CHAMPION ENTERPRISES, TRAVELERS INSURANCE COMPANY

This case involves a lien claimant, Monrovia Memorial Hospital, appealing a WCJ's order to further develop the record by obtaining an independent bill review opinion on the value of their services. The Appeals Board dismissed the Petition for Reconsideration, finding the order interlocutory and not a final decision. The Board also denied the Petition for Removal, concluding that the lien claimant failed to demonstrate significant prejudice or irreparable harm. The Board affirmed the WCJ's decision to use an impartial bill reviewer, rejecting claims of bias, and noted parties were given an opportunity to address the review's merits.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalLien ClaimantWCJIndependent Bill ReviewerSubstantive RightProcedural OrderInterlocutory DecisionPrejudice
References
Case No. ADJ1003604 (VNO 0473994)
Regular
May 10, 2016

MARIO CARRASCO vs. CITY OF LOS ANGELES

Lien claimant Western Medical Center (Western) sought reconsideration of an Independent Bill Review (IBR) determination that found no reimbursement warranted for medical services. Western argued the IBR determination was plainly erroneous because the defendant failed to provide a contract justifying payment below the official medical fee schedule. However, the Board dismissed Western's petition, finding it premature and improperly filed. Western failed to exhaust the required statutory appeal process to the Workers' Compensation Appeals Board trial level before filing for reconsideration.

Workers' Compensation Appeals BoardIndependent Bill ReviewAdministrative DirectorMaximus Federal ServicesOfficial Medical Fee ScheduleStipulations and AwardCumulative Trauma InjuryLumbar Spinal SurgerySecond Bill ReviewExplanation of Benefits
References
Case No. ADJ 1293553 (VNO 0460149)
Regular
May 12, 2016

CHARLES HOLDER vs. TROY CHRISTIAN dba ADVENTURE LIMOUSINE, THE HARTFORD INSURANCE COMPANY

This case concerns a billing dispute for medical treatment provided to applicant Charles Holder. The Workers' Compensation Appeals Board (WCAB) has remanded the matter for the trial judge to determine if Independent Bill Review (IBR) was properly initiated for services rendered on or after January 1, 2013. The Court of Appeal ordered this remand due to uncertainty regarding whether the defendant provided adequate explanations of review, which is a prerequisite for IBR. If IBR was not properly initiated, the WCAB retains jurisdiction over the dispute.

Workers' Compensation Appeals BoardRemandIndependent Bill ReviewExplanation of ReviewLabor Code section 4603.2Official Medical Fee ScheduleLien ClaimantJurisdictionTrial LevelFindings
References
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
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