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

Case No. ADJ1083014 (POM 0275607) ADJ4477705 (POM 0275608)
Regular
May 29, 2009

LILIAN SOTO vs. PM GLOVES, INC., STATE COMPENSATION INSURANCE FUND

This case involved a lien claimant seeking payment for an MRI. The Workers' Compensation Judge initially disallowed the lien for failing to meet Labor Code section 5703 requirements. The Appeals Board granted reconsideration, finding the WCJ erred by strictly applying section 5703. They determined that other evidence, including the treating physician's report referenced in a settlement, established the validity of the MRI expense. Therefore, the Board allowed the lien claim for the MRI.

Lien claimantReconsiderationLabor Code Section 5703Labor Code Section 4626Finding and OrderWorkers' Compensation Judge (WCJ)Compromise and Release (C&R)MRILumbar SpineSelf-procured medical treatment
References
Case No. SAC 0345394
Regular
Feb 22, 2008

DIANA RICHMOND vs. STATE OF CALIFORNIA, DEPARTMENT OF JUSTICE, legally uninsured

The Workers' Compensation Appeals Board denied reconsideration of a decision that applied the 2005 Permanent Disability Rating Schedule. The applicant argued that a pre-2005 MRI and subsequent medical opinions indicated permanent disability, thus triggering the older 1997 Schedule. The Board found that the MRI report alone was insufficient and that the AME's opinion on prior permanent disability was too late to qualify for the exception.

Workers' Compensation Appeals BoardDiana RichmondState of California Department of Justicelegally uninsuredSAC 0345394Opinion and Order Denying ReconsiderationFindings and AwardFebruary 222008industrial injury
References
Case No. ADJ2289246 (MON 0362113) ADJ4589003 (MON 0362111) ADJ826510 (MON 0362112)
Regular
Jul 23, 2015

ORLANDO ORTEGA vs. CALIFORNIA CLOSET COMPANY, NATIONAL LIABILITY & FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for removal, upholding the administrative law judge's exclusion of a fax delivery confirmation. This evidence pertained to a utilization review decision that denied a lumbar MRI and was excluded for not being listed on the pretrial conference statement and being served late. The Board found the evidence was not properly admissible as rebuttal under Labor Code section 5704 as the timeliness of the UR decision was a central, expected issue.

Petition for RemovalUtilization ReviewWCJ evidentiary rulingfax delivery confirmationpretrial conference statementmandatory settlement conferenceLabor Code section 5704rebuttal evidencelumbar MRIclaims examiner
References
Case No. ADJ9506185
Regular
Jul 13, 2016

JIM NEWELL vs. COUNTY OF KERN

The Workers' Compensation Appeals Board denied the County of Kern's petition for reconsideration of an award to Jim Newell. The award was based on industrial cumulative trauma to the lumbar spine and hypertensive cardiovascular disease, including left ventricular hypertrophy (LVH). The County argued there was insufficient evidence of LVH and sought further medical development, specifically a cardiac MRI. The Board found that the existing medical evidence, including echocardiograms and expert testimony, constituted substantial evidence to support the LVH diagnosis, making further testing unnecessary.

Workers' Compensation Appeals BoardCounty of KernJim NewellSheriff's Sergeantcumulative traumalumbar spinecirculatory systemhypertensionhypertensive cardiovascular diseaseleft ventricular hypertrophy
References
Case No. ADJ795505 (LAO 0794863)
Regular
Feb 13, 2014

VICTORIA SHANLEY vs. HENRY MAYO NEWHALL MEMORIAL HOSPITAL, TRAVELERS INSURANCE CO.

The Appeals Board reconsidered a WCJ's decision upholding utilization review (UR) denials for an MRI and EMG. While other contentions regarding the UR physician's qualifications and licensing were dismissed based on precedent, the Board found the UR decisions invalid due to untimely communication. Specifically, the defendant failed to prove by substantial evidence that the UR decisions were communicated by phone, fax, or email within 24 hours of being made. The matter is returned to the trial level to determine medical necessity, as the UR denials are void.

Utilization ReviewLabor Code Section 4610Administrative Director Rule 9792.9Physician QualificationLicensing RequirementsCommunication TimeframesTimely CommunicationMedical NecessityIndependent Medical ReviewInvalid UR Decision
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. ADJ8588048
Regular
Jul 18, 2018

KELLY LUHMANN vs. TORRANCE UNIFIED SCHOOL DISTRICT

This case concerns a worker's compensation applicant who sought reconsideration of a decision upholding the denial of an MRI for a knee injury. While the administrative law judge initially found the Independent Medical Review (IMR) determination untimely, the Workers' Compensation Appeals Board (WCAB) clarified that the IMR was issued within the statutory timeframe after receiving supporting documentation. Crucially, the WCAB noted that even if the IMR were late, timeliness is not grounds for appeal, and a delay does not invalidate the IMR decision based on established case law. Therefore, the applicant is bound by the IMR's decision denying the MRI, and the petition for reconsideration was denied.

Independent Medical ReviewUtilization ReviewLabor Code Section 4610.6TimelinessSupporting DocumentationDirectory vs. Mandatory Time PeriodMedical NecessityMRIKnee InjuryPsyche Injury
References
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