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

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
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. 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. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. ADJ1296558 (SAC 0119213)
Regular
Apr 23, 2015

JOHN SABELBERG vs. DEPARTMENT OF CORRECTIONS MEDICAL FACILITY, STATE COMPENSATION INSURANCE FUND

This case involves applicant John Sabelberg's petition for reconsideration of a decision denying his appeal of an Independent Medical Review (IMR). The IMR upheld a utilization review decision that disallowed a prescription for Ambien, citing long-term use and contraindications with other prescribed medications and alcohol consumption. The Workers' Compensation Appeals Board denied reconsideration, holding that Labor Code section 4610.6(h) precludes challenging an IMR determination based on allegations of incorrect medical judgment. The Board found that applicant failed to demonstrate any grounds for overturning the IMR decision as required by statute.

WORKERS' COMPENSATION APPEALS BOARDIndependent Medical ReviewPetition for ReconsiderationFindings and OrderStipulated AwardIndustrial InjuryMedical Treatment Utilization ScheduleOfficial Disability GuidelinesUtilization ReviewPR-2 reports
References
1
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
0
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. ADJ2068970 (STK 0167616)
Regular
Jul 21, 2016

Norman McAtee vs. Briggs & Pearson Construction, State Compensation Insurance Fund

The applicant seeks reconsideration of a WCJ's decision that dismissed his appeal of an Independent Medical Review (IMR) determination regarding pain medication. The IMR found the medication medically unnecessary, but the applicant argues this was based on a plainly erroneous finding of fact regarding the applicable treatment guidelines. The Appeals Board granted reconsideration, finding the IMR determination was indeed based on a plainly erroneous interpretation of the medical treatment guidelines. Consequently, the Board rescinded the WCJ's decision and remanded the case for a new IMR by a different reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewPlainly Erroneous Finding of FactLabor Code Section 4610.6Medical Treatment GuidelineOpioid TherapyPermanent DisabilityVocational RehabilitationAdministrative Law JudgeReconsideration
References
1
Case No. ADJ8338903
Regular
Sep 19, 2016

IRMA DE LEON vs. SAFEWAY, INC.

This case concerns whether medical treatment provided within a Medical Provider Network (MPN) is subject to Utilization Review (UR) and Independent Medical Review (IMR). The Appeals Board reversed the WCJ, holding that MPN treatment is indeed subject to UR/IMR. Delays in IMR determinations do not invalidate them. The March 21, 2014 IMR determination was deemed binding as no grounds for appeal were established.

MPNUtilization ReviewIndependent Medical ReviewMedical Treatment Utilization ScheduleLabor Code section 4610Medical Provider NetworkRequest for AuthorizationDirectory vs. Mandatory Time PeriodMargarisSB 863
References
13
Case No. ADJ9920940
Regular
Apr 14, 2016

ROBERT TOM vs. BUILDING AND COMPUTER ELECTRIC, INC.; REPUBLIC UNDERWRITERS INSURANCE, administered by SEDGWICK CMS, INC.

This case concerns a dispute over the timeliness of an Independent Medical Review (IMR) determination. The applicant argued the IMR was untimely, granting the Workers' Compensation Appeals Board (WCAB) jurisdiction to review the medical treatment dispute. The WCAB reviewed the evidence and found no clear and convincing proof that the director violated statutory timelines in issuing the IMR determination. Therefore, the WCAB affirmed the original decision finding the IMR to be timely.

IMRPetition for ReconsiderationFindings and OrderUtilization ReviewAdministrative DirectorStatutory TimeframeLabor Code Section 4610Labor Code Section 4610.6ADR 9792.10.5(a)(1)Burden of Proof
References
0
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