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

Case No. FRE 0219842
Regular
Mar 11, 2008

ELBEY LONERO vs. MERCED TRANSPORTATION, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) reversed an administrative law judge's decision regarding the applicant's temporary disability end date, finding it should be March 24, 2005, based on an agreed medical evaluator's opinion. The WCAB affirmed the use of the 1997 Permanent Disability Rating Schedule, finding that a treating physician's pre-2005 report indicated permanent disability. Finally, despite the adjusted temporary disability period, the defendant was denied credit for overpayments, as the applicant acted in good faith and the payments were continued after receiving the AME's report.

WORKERS' COMPENSATION APPEALS BOARDELBEY LONEROMERCED TRANSPORTATIONINC.STATE COMPENSATION INSURANCE FUNDCase No. FRE 0219842OPINION AND DECISION AFTER RECONSIDERATIONbus driverindustrial injurylow back
References
Case No. ADJ8691337
Regular
Oct 17, 2014

ANTHONY CABRAL vs. HAL HAYS CONSTRUCTION, INC., OLD REPUBLIC INSURANCE COMPANY

This case involves an applicant who sustained a back and neck injury, seeking authorization for lumbar surgery. The defendant's utilization review (UR) denials for the surgery were found to be procedurally defective and, in one instance, untimely. The Appeals Board denied the defendant's petition for reconsideration. The Board found that due to the untimeliness of the June 9, 2014 UR denial, jurisdiction lay with the Board to determine medical necessity. Based on substantial medical evidence supporting the surgery, the Board upheld the original award of treatment.

Utilization ReviewProcedural DefectTimelinessMedical NecessityLumbar SurgeryRadiculopathyLaminectomyTreating PhysicianRequest for AuthorizationWorkers' Compensation Appeals Board
References
Case No. ADJ7669411
Regular
Jul 23, 2013

OSCAR HUERTA vs. HIGGINS & LOVETT CONSTRUCTION, TOWER SELECT INSURANCE CO.

This case involves a workers' compensation claim for a laborer injured on November 2, 2010, to his neck and back. The defendant disputes the finding of 51% permanent disability, primarily arguing that the panel qualified medical evaluator's (PQME) report was not substantial evidence. The Appeals Board has granted reconsideration to further review the PQME's lumbar impairment rating, specifically questioning whether "non-verifiable radicular complaints" sufficiently supported the DRE Category III rating. The Board has rescinded the prior award and returned the case for further development of the record.

Occupational Group 480Panel Qualified Medical Evaluator (PQME)Dr. DawdyDRE Category IIIRadiculopathyLumbar ImpairmentSubstantial Medical EvidenceFurther Development of the RecordAmended Findings and AwardLumbar Spine
References
Case No. ADJ9546300 ADJ9103215
Regular
Apr 21, 2015

JAMES TUBBS vs. FRESNO CHAFFEE ZOO, NATIONWIDE AGRIBUSINESS INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and reversed a prior decision, finding the applicant is not entitled to a second lumbar surgery. The WCAB concluded that the applicant failed to meet the burden of proof by providing substantial medical evidence demonstrating the surgery's reasonableness and necessity, as required by Labor Code sections 5705 and 4600. While acknowledging the prior successful surgery, the WCAB found Dr. Aryan's request lacked sufficient support based on established medical treatment guidelines. The dissenting opinion argued that substantial medical evidence supported the surgery and that the defendant's delays unfairly prejudiced the applicant.

ADJ9546300ADJ9103215lumbar spine injuryDr. Francisco UnguezDr. Henry AryanRequest for Authorization (RFA)surgery authorizationL4-S1 surgeryDubon IIsubstantial medical evidence
References
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
Case No. ADJ8611746
Regular
Feb 27, 2017

VILMA AGUILAR vs. SLATKIN RESIDENCE, STATE FARM INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The defendant argued the administrative law judge erred in awarding 17% permanent disability by relying on the applicant's treating physician over a qualified medical evaluator. The Board found the treating physician's opinion was well-supported by objective clinical findings and consistent with the diagnosis of lumbar radiculopathy. Therefore, the Board gave significant weight to the administrative law judge's findings and denied the petition.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardPermanent DisabilityPrimary Treating PhysicianQualified Medical EvaluatorMedical OpinionCredibility DeterminationsSubstantial EvidenceLumbar Radiculopathy
References
Case No. ADJ4001054 (SAC 0153565)
Regular
Jul 02, 2016

MARYANN MAYFIELD-WEIGANT vs. ROSEVILLE COMMUNITY HOSPITAL, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for BEAVER INSURANCE, a subsidiary of FREMONT COMPENSATION, in liquidation

This case concerns a worker's appeal of two Independent Medical Review (IMR) denials for prescription medication and lumbar surgery. The Administrative Law Judge (ALJ) found insufficient evidence to overturn the IMR decision for medication and noted the surgery IMR was late but upheld its validity. The Workers' Compensation Appeals Board denied reconsideration, affirming the ALJ's decision. They held that the timeliness of an IMR determination is directory, not mandatory, and therefore does not invalidate the decision, citing precedent.

Independent Medical ReviewIMRPetition for ReconsiderationWorkers' Compensation Appeals BoardWCJLumbar spine injuryUtilization reviewPrescription medicine authorizationLumbar surgery authorizationPlainly erroneous
References
Case No. ADJ10612927
Regular
Jul 30, 2018

ROBERT O'NEAL vs. MARTEN TRANSPORT LIMITED, ACE AMERICAN INSURANCE COMPANY, CANNON COCHRAN MANAGEMENT SERVICES, INCORPORATED

The Workers' Compensation Appeals Board denied Marten Transport's petition for reconsideration. The Board affirmed the finding of industrial injury to the applicant's neck and lumbar spine, based on medical evidence of immediate complaints and the doctor's opinion of causation. The Board also upheld the denial of apportionment, as no reporting physician found a basis for it and the defendant failed to prove apportionment despite opportunities. The original award included temporary and permanent disability, plus further medical treatment.

Workers' Compensation Appeals BoardMarten Transport LimitedAce American Insurance CompanyCannon Cochran Management Servicesindustrial injuryneck injurylumbar spine injurytemporary disabilitypermanent disabilityapportionment
References
Case No. ADJ470132 (GOL 0100305), ADJ1890831 (GOL 0100306)
Regular
Sep 20, 2010

KAREN MCCORMICK vs. PACIFIC CAPITAL BANCORP, STATE COMPENSATION INSURANCE FUND, ST. PAUL TRAVELERS

Here's a summary of the case in four sentences for a lawyer: The Workers' Compensation Appeals Board denied SCIF's petition for reconsideration, affirming the WCJ's findings. The Board found Dr. Scheinberg's medical reports admissible and that applicant sustained an industrial injury to her lumbar spine on October 22, 2001, with permanent disability rated under the 1997 PDRS. The Board also rejected SCIF's Statute of Limitations defense and its claims regarding cumulative trauma and apportionment. SCIF's contentions regarding Dr. Scheinberg's reports, the lumbar spine injury, cumulative trauma, statute of limitations, PDRS application, and apportionment were all denied.

WCABSCIFAMELabor Code section 4628Statute of LimitationsWCAB Rule 104581997 PDRSpermanent disabilityapportionmentcumulative trauma
References
Case No. ADJ11184599, ADJ11184523
Regular
Feb 24, 2020

Gregory White vs. Sky 2 Collision Corporation, Illinois Midwest Insurance Company, Inc., National Casualty Company

The Workers' Compensation Appeals Board denied Gregory White's petition for reconsideration of a $47\%$ permanent disability award. White argued he was permanently totally disabled due to vocational limitations, but the Board found substantial evidence supported his ability to benefit from vocational rehabilitation. The Board affirmed the Administrative Law Judge's finding that White was not permanently totally disabled and that his vocational expert's report was less persuasive than the defense vocational expert's. Issues regarding vocational costs were deferred pending a separate petition.

Cumulative traumaSpecific injuryLow back injuryLumbar spineBacterial infectionStreptoccocusLaminectomyPermanent disabilityVocational rehabilitationQualified injured worker
References
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