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Case Law Database

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

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. 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. ADJ7951527
Regular
Oct 03, 2016

RONALD COYLE vs. DANE COYLE CUSTOM HOMES, INC.

The defendant sought reconsideration of an award for an applicant's industrial back injury, challenging the timeliness of the utilization review (UR) denial and the necessity of proposed spinal surgery. The Board denied reconsideration, affirming that the defendant failed to prove timely communication of the UR denial as required by law. Furthermore, substantial evidence, including reports from the treating physician and Agreed Medical Evaluator, supported the necessity of the lumbar fusion surgery. The Board found the defendant's arguments insufficient to rebut the expert medical opinions presented.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryUtilization Review (UR) DenialTimelinessFurther Medical TreatmentSpinal SurgeryLumbar FusionRequest for Authorization (RFA)
References
2
Case No. ADJ10034122
Regular
Dec 22, 2017

CRYSTAL WYANT vs. AMERICAN MEDICAL RESPONSE, ACE AMERICAN INSURANCE COMPANY

This case concerns an applicant's industrial back injury requiring lumbar spinal fusion. Defendants sought to overturn a prior award granting ongoing medical treatment, arguing a subsequent Utilization Review (UR) certification was invalid. The Appeals Board denied reconsideration, finding the UR process was correctly followed. A second Request for Authorization (RFA) submitted by the applicant's physician included "Change in Material Facts," triggering a new review. This second UR decision, dated September 11, 2017, authorized the surgery as medically necessary, superseding the earlier denial.

Utilization ReviewIndependent Medical ReviewReconsiderationFindings and AwardAdministrative Law JudgeLabor Code Section 4610Request for AuthorizationLumbar Spinal FusionMedical TreatmentChange in Material Facts
References
4
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. 2023 NY Slip Op 02158 [215 AD3d 1205]
Regular Panel Decision
Apr 27, 2023

Matter of Soler v. Donato, Inc.

The claimant, Wilfredo Soler, suffered work-related back and hip injuries in August 2017. Following a denial by a Workers' Compensation Law Judge in August 2021 for lumbar fusion surgery, the Chair of the Workers' Compensation Board initially authorized the surgery in November 2021. However, this authorization was subsequently rescinded by the Chair due to the prior denial on identical medical evidence. The Workers' Compensation Board then denied Soler's application for review of the Chair's rescission, deeming it outside its scope of review. The Appellate Division, Third Department, affirmed the Board's decision, concluding that orders of the Chair are not subject to review by the Board under Workers' Compensation Law § 23.

Lumbar fusion surgeryAuthorization for treatmentRescission of orderBoard reviewAppellate DivisionScope of reviewTreating physicianEmployerInsurance carrierMedical evidence
References
3
Case No. MISSING
Regular Panel Decision
Sep 02, 2014

Matter of Pinkhasov v. Auto One Insurance

The claimant's workers' compensation claim, initially established in 2006 for various work-related injuries, was reopened in 2012 due to worsening lower back pain leading to lumbar fusion surgery in 2013. A Workers’ Compensation Law Judge (WCLJ) awarded temporary total disability benefits post-surgery, a decision upheld by the Workers’ Compensation Board panel. The employer's carrier appealed, challenging the causal relationship between the 2006 accident and the subsequent medical treatment. The Appellate Court reversed the Board's decision, finding that the medical evidence, including an independent medical examination report, did not establish a rational basis for a causal relationship, and remitted the matter for further proceedings.

Workers' CompensationTemporary Total DisabilityCausal RelationshipLumbar Fusion SurgeryMedical EvidenceIndependent Medical ExaminationReopened ClaimAppellate ReviewWorkers' Compensation LawBack Injury
References
7
Case No. 535327
Regular Panel Decision
Apr 27, 2023

In the Matter of the Claim of Wilfredo Soler

Wilfredo Soler appealed a Workers' Compensation Board (WCB) decision denying his request for full Board review. Soler's claim for work-related injuries was established, and he was initially denied authorization for lumbar fusion surgery by a Workers' Compensation Law Judge (WCLJ). Although the Chair of the WCB later granted the request, this order was subsequently rescinded because the WCLJ had already denied the same request based on identical medical evidence. The WCB denied Soler's application for review, asserting that a Chair's order falls outside its scope of review under Workers' Compensation Law § 23. The Appellate Division affirmed the Board's decision, concluding that the Chair's orders are not subject to Board review.

Workers' CompensationAppealBoard ReviewMedical AuthorizationLumbar Fusion SurgeryRescission OrderScope of ReviewWorkers' Compensation LawJudicial ReviewAppellate Division
References
3
Case No. MISSING
Regular Panel Decision
Apr 03, 1995

Adams v. Alexander's Deptment Stores of Brooklyn, Inc.

Plaintiff Janie Adams alleged that she slipped and fell on melted ice cream at Kings Plaza Mall, sustaining injuries that required lumbar spine fusion. Defendant Ogden Services Corporation, responsible for common area maintenance, moved for summary judgment. The Supreme Court denied the motion, finding a triable issue of fact regarding notice. However, on appeal, the order was reversed, and the complaint dismissed. The Appellate Division found that Adams failed to make a prima facie case against Ogden, lacking evidence that Ogden created or had actual or constructive notice of the hazardous condition. Furthermore, an unsworn statement by a witness was deemed to be without evidentiary value, insufficient to defeat summary judgment.

Slip and FallPremises LiabilitySummary JudgmentActual NoticeConstructive NoticeEvidentiary ValueUnsworn StatementAppellate ReviewMaintenance ContractIce Cream
References
9
Case No. 531582
Regular Panel Decision
May 13, 2021

Matter of Matteliano v. Trinity Health Corp.

Caitlyn Matteliano, a nurse assistant, suffered work-related back, knee, and leg injuries in 2015 and 2018. Her treating orthopedic surgeon, Franco Vigna, requested authorization for multi-level lumbar fusion surgery and an external bone growth stimulator due to persistent pain and degenerative disc disease, despite conservative treatments. The employer denied this request based on an independent medical examination by Anthony Leone, who deemed the surgery aggressive and inappropriate given the lack of instability. A Workers' Compensation Law Judge initially denied the request, but the Workers' Compensation Board approved it. The employer appealed, and the Appellate Division, Third Department, affirmed the Board's decision, finding substantial evidence in Vigna's testimony to support the surgery's authorization under medical treatment guidelines for degenerative disc disease where non-surgical management has failed.

Workers' CompensationLumbar Fusion SurgeryMedical Treatment GuidelinesDegenerative Disc DiseaseDiscogenic Back PainIndependent Medical ExaminationPrior AuthorizationAppellate ReviewNurse AssistantWork Injury
References
9
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