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

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 The Board has rescinded the prior award and returned the case for further development of the record.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. ADJ2946461
Regular
May 18, 2008

LUCIO AGUIRRE vs. PIONEER PACKING, INC., STATE COMPENSATION INSURANCE FUND

This case involves a lien claim by an anesthesiologist, Dr. Vaughn, for services rendered during a lumbar IDET procedure performed by Dr. Sandhu on an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, reversing the trial judge's denial of the lien. The WCAB found that the anesthesiology services were reasonable and necessary at the time they were performed, as Dr. Vaughn had no reason to question the treating physician's judgment. Furthermore, the Board held that the defendant insurer could not deny liability based on prior silence regarding Dr. Sandhu's requested treatment, citing principles of implied authorization and equitable liability. The WCAB allowed Dr. Vaughn's lien, with the specific amount to be determined by the parties or the trial judge.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationIndustrial InjuryRight LegBackState Compensation Insurance FundAnesthesiologyTreating PhysicianSurgery
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. ADJ10679103
Regular
Dec 14, 2017

LARRY SYKES vs. THE ANSCHUTZ CORPORATION, STARR INDEMNITY & LIABILITY COMPANY

The Workers' Compensation Appeals Board granted reconsideration of a prior finding of industrial injury to the applicant's lumbar spine. The Board found that the existing medical reporting from Dr. Hong, Dr. Jamasbi, and the PQME Dr. Schofferman did not constitute substantial evidence to support this lumbar spine injury finding. Therefore, the case is returned to the trial level to develop the record further on the lumbar spine injury issue.

Workers' Compensation Appeals BoardPetition for ReconsiderationIndustrial InjuryCervical SpineThoracic SpineLumbar SpineStagehandSecurity OfficerMedical Treatment RecordsSubstantial Evidence
References
Case No. ADJ10384099
Regular
Jan 29, 2018

RODOLFO RODRIGUEZ vs. ROBERT BOSCH AFTERMARKET DIVISION, ZURICH NORTH AMERICA

The Appeals Board granted reconsideration to amend the finding of fact, clarifying that the applicant sustained a compensable injury to his lumbar spine arising out of and occurring within the course of employment. While medical evidence supported the lumbar spine injury, the Board deferred the issue of lower extremities as an injured body part for further development. This decision affirmed the original finding regarding the lumbar spine, based on applicant's credible testimony and medical opinions from Drs. Hutchinson and Schaffzin.

AOE/COELumbar spineLower extremitiesPetition for ReconsiderationFinding of FactWCJMedical evidencePreexisting conditionAggravationLighting up
References
Case No. AD10769216
Regular
Dec 13, 2019

Richard Hovannisian vs. UCLA, Permissibly Self-Insured, Administered By SEDGWICK CMS

The WCAB granted reconsideration and deferred issues of lumbar spine injury and permanent disability from a prior award. The WCJ's decision relied on a QME report that failed to establish industrial causation for the lumbar spine injury and lacked sufficient explanation for departing from AMA Guides methodology for permanent disability ratings. The Board found these deficiencies meant the decision was not based on substantial medical evidence. Further proceedings are required for the QME to adequately address causation, rating methodology, and lumbar spine classification.

WCABPetition for ReconsiderationFindings of Fact & Awardindustrial injurylumbar spinepermanent disabilitysubstantial medical evidencedue processDisability Evaluation Unitpanel qualified medical evaluator
References
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