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

Case No. ADJ12663627
Regular
Mar 18, 2025

JIAN KALLASH vs. MACYS, Permissibly Self-Insured, Administered by SEDGWICK CLAIMS MANAGEMENT

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by Macy's, administered by Sedgwick Claims Management. The petition challenged the WCJ's Findings and Award, which found medical treatment, specifically an anterior lumbar interbody fusion at L5-S1, to be reasonable and necessary for applicant Jian Kallash. The Board affirmed the WCJ's decision, concluding that the Utilization Review (UR) denial was untimely and that substantial medical evidence from treating physicians and a QME supported the medical necessity of the requested treatment after conservative measures failed. The decision was issued timely within the 60-day statutory period as outlined in Labor Code section 5909.

Petition for ReconsiderationLabor Code section 5909Appeals BoardWCJEAMSTransmission dateNotice of transmissionReport and RecommendationExpedited HearingUtilization Review (UR) denial
References
9
Case No. SAL 0107786
Regular
Oct 16, 2007

MOLLY KIRKPATRICK vs. DOMINICAN SANTA CRUZ HOSPITAL, PSI ADMINISTERED BY OCTAGON RISK SERVICES

This case concerns an injured worker who had cervical spine surgery involving diskectomy, vertebrectomy, decompression, and fusion. The defendant sought reconsideration of an award granting temporary disability benefits beyond the statutory 104-week limit, arguing the surgery was not an amputation. The Appeals Board rescinded the prior award and returned the matter for further proceedings, as the definition of "amputation" in precedent excludes internal body parts like those removed during spinal fusion.

Workers' Compensation Appeals BoardDominican Santa Cruz HospitalOctagon Risk ServicesMolly KirkpatrickIndustrial InjuryCervical Spine SurgeryTemporary Disability IndemnityLabor Code Section 4656(c)AmputationDiskectomy
References
1
Case No. ADJ1438639 (GRO 0024593) ADJ3262777 (GRO 0025366)
Regular
Sep 20, 2011

Dennis Timmons vs. CALIFORNIA MENS COLONY, STATE COMP. INS. FUND, SUBSEQUENT INJURIES BENEFITS TRUST FUND

This case concerns applicant Dennis Timmons' petition for reconsideration of a denial of Subsequent Injuries Benefits Trust Fund (SIBTF) benefits. The Appeals Board reversed a prior award, finding applicant failed to prove a pre-existing permanent partial disability from a 1991 cervical fusion surgery prior to his 2000 industrial injury. Applicant argued the fusion itself constituted a previous impairment and that SB 899's apportionment changes should apply, but the Board affirmed its decision. The Board reiterated that contemporaneous medical evidence is required for SIBTF eligibility, and that SB 899 did not alter SIBTF's established requirements.

Subsequent Injuries Benefits Trust FundSIBTFpermanent disabilitypre-existing disabilitycervical fusionApril 132000 industrial injurySB 899apportionment to causationLabor Code section 4751
References
2
Case No. ADJ6619207 ADJ6736606
Regular
May 24, 2010

ALBERTO ALVAREZ vs. AKT DEVELOPMENT CORPORATIONS, INSURANCE OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration of a decision awarding lumbar fusion surgery, finding the WCJ erred by solely relying on the *Cervantes* decision regarding timely utilization review. The Board determined that the defendant's utilization review timeliness was unclear, and the parties had agreed to an Agreed Medical Examiner (AME) to resolve the surgery dispute before *Cervantes* was issued. Furthermore, the Board held that the treating physician's recommendation for surgery must constitute substantial evidence, which was not definitively established here. Therefore, the matter was returned for further development of the record, requiring the treating physician to address the AME's concerns regarding the necessity of fusion surgery.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationJoint Findings Award and OrderIndustrial InjuryLumbar FusionUtilization ReviewCervantes v. El Aguila Food ProductsSubstantial Medical EvidenceExpedited Hearing
References
3
Case No. MISSING
Regular Panel Decision
Jun 28, 2007

Lucas v. Fulton Realty Partners

The plaintiffs, Audobon Lucas and Lawrence J. Brex, were injured while dismantling large steel storage cages in a warehouse owned by 30 Warren Place Corp. Lucas, working on a scaffold, was struck by falling sheet metal from a cage he was prying from a wall, and Brex was injured attempting to assist him. The Supreme Court granted the plaintiffs' motion for summary judgment on the issue of liability under Labor Law § 240 (1). The appellate court affirmed this decision, finding that the plaintiffs were engaged in "altering" work covered by the statute and that the falling object liability applied as the unsecured sheet metal posed a significant risk. The court also determined that the appellant's unsworn workers' compensation forms were insufficient to raise a triable issue of fact regarding causation.

Personal InjuryLabor LawSection 240(1)Summary JudgmentLiabilityFalling ObjectConstruction AccidentWarehouseScaffold IncidentAltering Work
References
19
Case No. MISSING
Regular Panel Decision

Madigan v. United Parcel Service, Inc.

Plaintiff Arthur J. Madigan sustained injuries after falling from a reinforcing rod cage while working on a UPS delivery facility construction, leading him to file a Labor Law § 240 claim. The Supreme Court initially denied his motion for partial summary judgment and granted the defendants' cross-motion to dismiss the claim. However, the appellate court reversed this decision, finding that the plaintiff's work involved a significant elevation-related risk, thereby making Labor Law § 240 applicable. The court also dismissed the defendants' arguments regarding the unwitnessed nature of the accident, the availability of safety devices, and instructions not to walk on the cages. Furthermore, it established that UPS, as the overseeing entity and parent company of Newbany, was liable under the statute. Consequently, the appellate court unanimously reversed the lower court's order, granted the plaintiff's motion for partial summary judgment, and denied the defendants' cross-motion.

Construction AccidentLabor LawFall from HeightSummary JudgmentAppellate ReviewEmployer LiabilitySafety DevicesElevation-Related RiskWorker InjuryNew York Law
References
13
Case No. ADJ6640587
Regular
Dec 06, 2011

TODD CAGE vs. THE KROGER COMPANY DBA RALPHS GROCERY

The Workers' Compensation Appeals Board (WCAB) granted the defendant's (The Kroger Company) petition for reconsideration of prior decisions. This action was taken to allow the Board further time to thoroughly study the factual and legal issues presented. The granting of reconsideration is for the purpose of a complete review and to issue a just decision. All future filings in this case must be submitted directly to the WCAB Commissioners in San Francisco.

Petition for ReconsiderationFindings and OrderStatutory Time ConstraintsFactual and Legal IssuesDecision After ReconsiderationOffice of the CommissionersSan FranciscoAnaheim District OfficePermissibly Self-InsuredSedgwick CMS
References
0
Case No. ADJ6882824
Regular
Mar 02, 2012

ROBERTA RUST vs. PUBLIC STORAGE, AMERICAN INTERNATIONAL GROUP/CHARTIS FUSION GROUP administered by SEDGWICK CMS

The applicant, Roberta Rust, sought reconsideration of a prior WCAB decision. The Board granted reconsideration because a further review of the factual and legal issues is necessary for a just and reasoned decision. The case file will be transferred to the Office of the Commissioners for further proceedings. All future communications must be directed to the San Francisco office, not the Van Nuys District Office.

Workers' Compensation Appeals BoardPetition for ReconsiderationDecision After ReconsiderationStatutory Time ConstraintsFactual and Legal IssuesJust and Reasoned DecisionOffice of the CommissionersVan Nuys District OfficeADJ6882824
References
0
Case No. ADJ8436467
Regular
Sep 09, 2015

CELEINE MELENDEZ vs. KOHL'S DEPARTMENT STORE, NEW HAMPSHIRE INSURANCE COMPANY

This case concerns an employee seeking workers' compensation for back surgery, specifically an anterior lumbar discectomy and fusion. The employer contested the necessity of the surgery, arguing the administrative law judge erred in approving it. The Appeals Board affirmed the judge's decision, finding the request for authorization was valid as it reflected a change in circumstances. Therefore, the defendant is ordered to provide the authorized surgical treatment.

Workers' Compensation Appeals BoardReconsiderationUtilization ReviewAnterior Lumbar Discectomy and FusionLabor Code section 4610(g)(6)Primary Treating PhysicianIndependent Medical ReviewFindings and OrderLumbar SpineMedical Treatment Authorization
References
0
Case No. ADJ441410
Regular
Oct 03, 2008

HAYDEE NUNEZ vs. FAIRMONT MIRAMAR HOTEL, COMMERCE & INDUSTRY INSURANCE COMPANY

The Appeals Board denied the lien claimant's petition for reconsideration, affirming the WCJ's denial of the remaining lien balance. The Board is returning the case to the trial level to investigate potential sanctions against the lien claimant for its actions in filing the petition for reconsideration, citing alleged procedural defects and bad faith. The WCJ's original finding was that the outpatient fusion surgery was not permitted under Medicare Guidelines and the defendant paid more than the reasonable value of the services.

Workers Compensation Appeals BoardFairmont Miramar HotelCommerce & Industry Insurance CompanyAIG Domestic ClaimsOutpatient Spine & Surgery CenterLien claimantIndustrial injuryLow back injuryOutpatient fusion surgeryMedicare Guidelines
References
1
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