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

Case No. ADJ2709955 (MON 0356320)
Regular
Jun 21, 2017

Mario Cocola vs. California Hospital Medical Center

The Workers' Compensation Appeals Board denied Mario Cocola's petition for reconsideration, upholding the finding that he sustained $69\%$ permanent disability from industrial injuries. Cocola argued the administrative judge erred by disregarding the Agreed Medical Examiner's opinion that he was totally disabled from the open labor market due to orthopedic injuries. The Board agreed with the judge's report that the physician's opinion lacked sufficient objective basis for the change in work restrictions. A dissenting opinion argued the medical and vocational evidence supported a $100\%$ permanent disability finding and requested clarification from the medical examiner.

Petition for ReconsiderationFindings of Fact and Awardpermanent disabilitycumulative traumalumbar spinecervical spinepsychecervicogenic headachesEmergency Unit CoordinatorAgreed Medical Examiner
References
1
Case No. ADJ11255525
Regular
Dec 02, 2019

GWENDOLYN JOHNIGAN vs. UC DAVIS MEDICAL CENTER

This case involves an applicant denied workers' compensation benefits for industrial injury to her right leg and knee, with the Workers' Compensation Appeals Board (WCAB) denying her petition for reconsideration. The WCAB adopted the administrative law judge's finding that the applicant did not sustain industrial injury, relying on a panel qualified medical evaluator's opinion that the work duties were insufficient to cause an injury. The applicant argued the medical evidence was not substantial and sought further development of the record. However, the WCAB found the applicant failed to meet her burden of proof with substantial medical evidence. A dissenting opinion argued the medical evidence was insubstantial and required further development.

Petition for ReconsiderationPanel Qualified Medical EvaluatorOrthopedistSubstantial Medical EvidenceFurther DevelopmentSupplemental ReportingDeposition TestimonyIndustrial InjuryRight LegRight Knee
References
4
Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
Case No. ADJ519728
Regular
Aug 08, 2011

LOWELL BAPTISTE vs. METROPOLITAN TRANSIT AUTHORITY

The Workers' Compensation Appeals Board granted reconsideration of a prior award finding industrial injury and temporary total disability dating back to 2000. The Board found that the medical opinion relied upon by the workers' compensation judge was not substantial evidence due to staleness, lack of complete records, and insufficient specialization. To ensure a fair resolution, the Board ordered new evaluations by independent orthopedic and psychiatric physicians, who will report on all outstanding medical issues.

Workers' Compensation Appeals BoardReconsiderationCompelling Medical EvaluationsTemporary Total DisabilityIndustrial InjuryOrthopedicsPsychiatrySubstantial EvidenceMedical OpinionWCJ
References
2
Case No. ADJ4442180 (MON 0225200)
Regular
Nov 18, 2010

ERMA LESTER vs. STATE OF CALIFORNIA, BOARD OF EQUALIZATION, STATE COMPENSATION INSURANCE FUND, et al

The Workers' Compensation Appeals Board granted reconsideration, reversing a prior award. The Board found that the Independent Medical Evaluator's (IME) April 2010 deposition testimony, which suggested that the applicant's fibromyalgia could not be medically apportioned between two distinct industrial injuries, was not substantial evidence. Consequently, the Board reinstated two separate 50% permanent disability awards for each injury, relying on earlier IME opinions that allowed for apportionment. The Board reasoned that the IME's later opinion lacked a medical basis and appeared to be influenced by legal considerations rather than medical findings.

FibromyalgiaCumulative TraumaApportionmentMedical-Legal OpinionsIndependent Medical EvaluatorPermanent DisabilityCausationSubstantial EvidenceReconsiderationBoard En Banc
References
4
Case No. ADJ1225282 (VNO 0377064) ADJ3069813 (VNO 0377062)
Regular
May 05, 2015

CHERYL CASTRILLO vs. CATHOLIC HEALTH CENTER WEST dba. MARIAN MEDICAL CENTER

The Workers' Compensation Appeals Board affirmed a prior decision finding that the defendant properly completed and communicated utilization review decisions, and that the applicant failed to prove the Independent Medical Review (IMR) process was biased. The Board held that delays in IMR decisions do not invalidate them, citing a relevant appellate court opinion. Furthermore, the Board lacks the authority to rule on the constitutionality of the relevant Labor Code sections. Therefore, the original decision was upheld.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewAdministrative DirectorPetition for ReconsiderationFindings of Fact and OrderWCJLabor Codeconstitutionalitytimeliness
References
3
Case No. ADJ6907549, ADJ9156151
Regular
May 28, 2015

Leticia Avila vs. University of California Irvine Medical Center, SEDGWICK CMS

This case clarifies that an employee must *receive* their Independent Medical Review (IMR) application within 30 days of the Utilization Review (UR) denial, plus a 5-day extension if the denial was served by mail. The applicant's IMR application was deemed untimely because it was received by the Administrative Director one day after the extended deadline. This decision affirms the WCJ's finding that the applicant's IMR application was not filed within the mandatory statutory timeframe. The concurring opinion stresses the importance of timely adherence to all timeframes within the UR/IMR process.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewLabor Code section 4610.5(h)(1)Administrative Director's Rule 9792.10.1(b)(2)Code of Civil Procedure section 1013(a)timely filingsubmission datereceipt dateservice by mail
References
0
Case No. ADJ9709726
Regular
Jun 25, 2015

LAURA NUNEZ vs. SUTTER PACIFIC MEDICAL FOUNDATION, SUTTER HEALTH

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The defendant challenged the finding of industrial injury AOE/COE for thoracic outlet syndrome, arguing it wasn't an issue for trial and the medical evidence was insufficient. The Board found that thoracic spine injury was an issue and that Dr. Avery's opinion provided substantial medical evidence to support the thoracic outlet syndrome finding. Any potential defects in the original WCJ opinion were cured by the WCJ's subsequent report.

Thoracic outlet syndromeAOE/COEPetition for Reconsiderationsubstantial medical evidenceG. James Avery M.D.Steven Bratman M.D.industrial injuryapportionmentWCJlabor code 5313
References
1
Case No. ADJ364166 (LAO 0879384) ADJ3925942 (LAO 0881103)
Regular
Jun 25, 2015

ELIBORIO MAYORGA vs. DEXTER AXLE CHASSIS GROUP, AIG, GALLAGHER BASSETT SERVICES, INC.

The Appeals Board reconsidered a joint findings and award, finding the initial determination of permanent disability and apportionment for psyche and hypertension injuries lacked substantial evidence. Specifically, the Board found that medical opinions on apportionment from different specialties could not be substituted or combined without independent justification from each specialist. Consequently, the case is remanded to the trial level for further development of the record to obtain independent apportionment opinions from the physicians regarding the psyche and hypertension injuries. The remainder of the WCJ's decision, including temporary disability findings, is affirmed.

ApportionmentCumulative traumaSpecific injuryPermanent disabilityTemporary total disabilityLife pensionReconsiderationWorkers' Compensation Appeals BoardMedical-legal disputeCausation
References
9
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
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