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

Case No. SRO 108858
Regular
Aug 13, 2008

RANDY S. HOGAN, M.D. vs. CITY AND COUNTY OF SAN FRANCISCO, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

The Workers' Compensation Appeals Board (WCAB) denied the defendant's petition for reconsideration, upholding the finding of industrial injury to the applicant's liver. However, the WCAB granted the lien claimant's petition, rescinding the established date of injury as December 1994. The case is returned to the trial level for further proceedings to determine the correct date the applicant first suffered a compensable disability from the liver injury.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderLabor Code §5402Labor Code §5412Date of InjuryIndustrial InjuryCompensable DisabilityHepatitis CLiver Disease
References
Case No. ADJ2128084 (VNO 0428792) ADJ1712801 (VNO 0428794) ADJ346332 (VNO 0428790) ADJ6882145
Regular
Feb 07, 2017

NAYER GARAS vs. RXI PLASTICS, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board rescinded the WCJ's order for continuing home health care, finding the record insufficient to support the decision. Although the parties stipulated to timely utilization review denials, the specific RFAs forming the basis for these denials were not adequately documented in the record. The Board determined it could not ascertain whether the defendant's reliance on UR was inappropriate or if the applicant's care was improperly terminated without a change in circumstances. The case is returned to the WCJ for further proceedings to develop a complete record.

Workers' Compensation Appeals BoardReconsiderationPetition for ReconsiderationHome Health CareUtilization ReviewRequest for AuthorizationTreating PhysicianAdministrative Law JudgeLiver TransplantMedical Necessity
References
Case No. ADJ376655 (SJO 0257571)
Regular
Dec 26, 2014

JORDAN STONE vs. ACHIEVE KID.; CAPS-SIG

In this workers' compensation case, the Appeals Board reversed a prior decision denying an employer's appeal of an Independent Medical Review (IMR) determination. The Board found the IMR determination for a knee cartilage transplant was plainly erroneous and acted in excess of the Administrative Director's powers. This was due to a direct contradiction between the IMR's finding of medical necessity and its stated rationale. Consequently, the Board granted the employer's appeal and remanded the case for a new IMR review by a different reviewer.

Workers' Compensation Appeals BoardIndependent Medical Review (IMR)Utilization Review (UR)Labor Code section 4610.6(h)Plainly erroneous findingsExpert opinionMedical necessityCartilage transplantRight kneeRemand
References
Case No. ADJ6801375
Regular
Jul 13, 2010

MICHAEL DAVID HERNANDEZ vs. VINCE'S ITALIAN TO GO, PREFERRED EMPLOYERS

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a prior award. The WCAB found that the applicant was not entitled to medical treatment outside the employer's Medical Provider Network (MPN) for a meniscus transplant or graft. The applicant failed to follow the required procedures for obtaining a second and third opinion within the MPN before seeking treatment from an out-of-network physician. Therefore, the WCAB concluded there was no showing that treatment outside the MPN was justified under the relevant rules.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNFurther Medical TreatmentSports Medicine DoctorMedical Meniscus TransplantGraft ProcedureDr. Patrick O'MearaDr. John DeSantisSubspecialist
References
Case No. ADJ10917168 (MF)
Regular
Oct 21, 2019

JACOB PIKE vs. CITY OF LONG BEACH

This case concerns an applicant seeking reconsideration of a Workers' Compensation Appeals Board decision denying a right knee meniscal transplantation. The judge found the requested treatment did not fall within presumptively correct Medical Treatment Utilization Standards (MTUS) or present sufficient scientific evidence to rebut the presumption. Applicant argued the physician's report constituted scientific evidence and supported medical necessity, but the Board affirmed the denial. The Board found the applicant failed to meet the burden of proof by a preponderance of scientific medical evidence for treatment outside MTUS guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Findings of Factindustrial injuryright knee meniscal transplantationUtilization Review (UR)Medical Treatment Utilization Standards (MTUS)Labor Code sections 4604.55307.27medically necessary
References
Case No. ADJ6899666 ADJ6899667
Regular
Jan 25, 2016

KIMBERLY CHAMBERS vs. UCLA MEDICAL CENTER, Permissibly SelfInsured, Administered By SEDGWICK CMS

This case concerns an applicant's industrial injury causing cardiovascular and digestive system damage. The Workers' Compensation Appeals Board dismissed the applicant's petition for reconsideration as moot due to the judge's rescission of a prior award. The Board granted the defendant's petition, limiting the applicant's total temporary disability to 104 weeks per Labor Code section 4656(c)(2). The issue of a 15% permanent disability increase under Labor Code section 4658(d)(2) was deferred for further proceedings.

Petition for ReconsiderationDismissalFindings of FactOrder and AwardWCJPhlebotomistIndustrial InjuryCardiovascular SystemTemporary DisabilityPermanent Disability
References
Case No. ADJ4261717 (FRE 0227914), ADJ2564944 (FRE 0224116)
Regular
Jan 19, 2017

Ann Swengel vs. CAMBRIDGE; AON CORPORATION, AMERICAN CASUALTY COMPANY OF READING, PENNSYLVANIA

The Appeals Board granted the defendant's petition for reconsideration, reversing the prior order that mandated a gym membership. The Board found that because the defendant timely submitted the request for authorization (RFA) to Utilization Review (UR), the UR's denial is not subject to review by the Board, nor is it subject to Independent Medical Review (IMR) if not timely appealed. Consequently, the applicant's petition for reconsideration and for penalties was denied. The Board emphasized that their jurisdiction regarding UR determinations is limited to timeliness.

Utilization ReviewIndependent Medical ReviewPetition for ReconsiderationFindings of Fact and OrderPrimary Treating PhysicianRequest for AuthorizationAdministrative Director's DeterminationMedical Treatment Utilization ScheduleLabor Code Section 5814.5Stipulations with Request for Award
References
Case No. ADJ3104033 (OAK 0342486)
Regular
Dec 12, 2020

JAMES BARNES vs. DEPARTMENT OF CORRECTIONS AND REHABILITATION, STATE OF CALIFORNIA

This case involves a correctional officer with stipulated industrial injuries to his heart, cardiovascular system, kidneys, sleep disorder, and psyche. The defendant sought reconsideration of an award of total permanent disability, arguing the presumption under Labor Code 3212.2 did not apply to the kidney condition and that apportionment was possible. The Appeals Board granted reconsideration, rescinded specific findings related to the kidney condition and presumption, but affirmed the total permanent disability award based on the combined effects of the presumed industrial heart trouble and admitted industrial kidney disease. The matter was returned to the trial level for further development of the record regarding the kidney issues and apportionment.

Workers' Compensation Appeals BoardDepartment of Corrections and Rehabilitationcorrectional officerindustrial injuryheart injurycardiovascular systemkidneyssleep disorderpsychetotal permanent disability
References
Case No. ADJ4687404 (ANA 0322707)
Regular
Jun 24, 2009

JACKIE MOORE vs. PHYSICIANS CLINICAL LABORATORY, INC.; CIGA, by its servicing facility, CAMBRIDGE INTEGRATED SERVICES, for, FREMONT INDEMNITY, in liquidation;, UNILAB CORPORATION/ CNA STANDARD, LINES,

The applicant sought removal of an order appointing a new medical evaluator, arguing the existing record was sufficient and the judge lacked objectivity. The Board denied removal, finding the judge's prior order to further develop the record was justified due to inconsistent medical opinions. The applicant also alleged judicial bias, but the Board found no evidence to warrant disqualification of the judge. Therefore, the petition for removal and request for disqualification were denied.

Workers' Compensation Appeals BoardPetition for RemovalRegular PhysicianLabor Code Section 5701DisqualificationJudicial DemeanorObjectivityAgreed Medical Evaluator (AME)HepatologyLiver Disease
References
Case No. ADJ7083586
Regular
Feb 10, 2015

JOSE PACHECO (Deceased) MARIA ELENA PACHECO (Widow) vs. HAWKER PACIFIC AEROSPACE, LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the widow's petition for reconsideration of the denial of her claim for death benefits. The applicant failed to prove that her deceased husband's industrial exposure contributed to his death from internal system injuries. The majority adopted the WCJ's report, finding no error in the denial. One commissioner dissented, arguing the record should be further developed regarding the decedent's specific workplace exposures to harmful agents like nickel and chromium, as his employment need only be a contributing cause.

Workers' Compensation Appeals BoardPetition for ReconsiderationIndustrial InjuryCumulative TraumaDeath BenefitMachinistNickelChromiumCyanideLiver Cancer
References
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