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

Case No. ADJ6538283
Regular
Jun 03, 2009

SOPHIA CALIX vs. TARGET CORPORATION, Permissibly Self-Insured and Administered By SEDGWICK, CLAIMS MANAGEMENT SERVICES

The Appeals Board granted reconsideration, rescinding the WCJ's finding that the defendant failed to comply with MPN regulations. The applicant received treatment outside the MPN on the date of injury but was transferred to MPN providers shortly thereafter. The Board found that the defendant provided timely notice of MPN rights and that the applicant did not suffer neglect in receiving medical treatment. The matter was returned to the trial level to clarify the record regarding initial MPN notification.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Administrative Director RulesPetition for ReconsiderationFindings and OrderWCJacute conditiontimely notificationClaim FormKnight v. United Parcel Service
References
Case No. ADJ9466570
Regular
Dec 24, 2014

ELVIRA HERNANDEZ vs. NEWCO FOODS, INC., Operating As JACK IN THE BOX, SECURITY NATIONAL, Administered By AMTRUST NORTH AMERICA

The Workers' Compensation Appeals Board granted reconsideration to clarify an earlier decision regarding a Medical Provider Network (MPN). The Board affirmed the finding that the defendant failed to prove the existence of a valid MPN. Consequently, findings related to MPN access standards and transfer of care were rescinded, with the applicant permitted to continue treatment outside the invalid MPN with her chosen physician. This decision primarily hinges on the defendant's failure to establish a legally compliant MPN.

Medical Provider NetworkMPNFindings of Fact and AwardPetition for Reconsiderationprimary treating physiciantransfer of careself-procured medical treatmentTitle 8section 9767.5(b)Title 8
References
Case No. ADJ11315508
Regular
Sep 12, 2018

SIERRA PRADO vs. PCG HOSPITALITY, TRAVELERS INSURANCE CO.

This case concerns an applicant's request to treat outside her employer's Medical Provider Network (MPN) due to alleged difficulties in scheduling an appointment with an MPN physician. The applicant argued the Medical Access Assistant (MAA) failed to secure an appointment with available MPN doctors, leading to a denial of care. The Workers' Compensation Appeals Board affirmed the WCJ's decision, finding no denial of care because the MPN list is not a guarantee of immediate appointment and the MAA reasonably attempted to find a suitable physician. The majority determined that the applicant did not exhaust reasonable efforts to find an MPN doctor, and a dissenting opinion argued the inaccurate MPN list constituted a failure to provide care, justifying out-of-network treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Medical Access Assistant (MAA)Primary Treating Physician (PTP)Denial of CareOut-of-Network TreatmentLabor Code Section 4600Labor Code Section 4616Cal. Code Regs. tit. 8§ 9767.5
References
Case No. ADJ8205235
Regular
Feb 06, 2013

HECTOR GOMEZ vs. FASTENAL, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

This case concerns an injured worker, Hector Gomez, who sought medical treatment outside his employer's Medical Provider Network (MPN). The Board overturned the finding that the employer lost control of medical treatment, finding that the employer's technical failure to schedule the initial MPN visit did not deny treatment. The Board also held that the worker could not select a non-MPN specialist simply because an MPN specialist declined to act as a primary treating physician. Therefore, the applicant must obtain treatment through the defendant's MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)SpecialistLabor Code section 4616.3Administrative Director's Rule 9767.6initial medical evaluationchange of physicianforfeiture of medical controlaccess standards
References
Case No. ADJ3823114 (MON 0252208)
Regular
Dec 03, 2015

ILANA BENLULU vs. BEVERLY SINAI TOWERS, SEDGWICK CLAIMS MANAGEMENT SERVICES, servicing facility for CIGA for RELIANCE INSURANCE COMPANY, in liquidation

This case concerns the proper transfer of an injured worker into a defendant's Medical Provider Network (MPN). The applicant contended she pre-designated her physician, avoiding MPN requirements, but provided no supporting evidence. The Board found that the defendant's prior attempts to transfer the applicant into the MPN were invalid due to insufficient notice or the MPN's failure to meet minimum access standards. Ultimately, the Board determined that a July 15, 2014 notice, properly served and containing all required information, effectively transferred the applicant into the MPN on August 14, 2014.

MPNMedical Provider NetworkReconsiderationFindings of FactWorkers' Compensation Appeals BoardLabor CodePre-designation of PhysicianContinuity of CareTransfer of CareMinimum Access Standards
References
Case No. ADJ7236056
Regular
Jul 21, 2011

KAREN MARTIN vs. MANPOWER, INC., GALLAGHER BASSETT SERVICES, INC.

This case concerns an applicant who sustained a left knee and back injury but also claimed injury to her neck and left shoulder. The applicant petitioned for reconsideration of an order requiring her to treat within the Medical Provider Network (MPN), alleging the MPN notice was defective due to its provision method and delayed list. The Board denied the petition, adopting the WCJ's reasoning that while there were initial MPN notice defects, they were corrected and do not exempt the applicant from MPN treatment. While acknowledging concern over the delay in providing a usable MPN list, the Board found no authority to overturn the original order.

Workers' Compensation Appeals BoardManpower Inc.Gallagher Bassett Services Inc.MPNMedical Provider Networkdefective noticeexpedited hearingFindings and OrderPetition for ReconsiderationWCJ
References
Case No. ADJ4030941
Regular
Jan 21, 2011

SALVADOR CERDA vs. CHARTER OAK UNIFIED SCHOOL DISTRICT, YORK INSURANCE SERVICES GROUP

The Workers' Compensation Appeals Board denied the defendant school district's petition for reconsideration regarding applicant Salvador Cerda's medical treatment. The Board found that applicant's treatment with Dr. Paz was within the defendant's Medical Provider Network (MPN), rendering moot any arguments about the adequacy of the MPN notices. While Dr. Paz was listed in the MPN at a Los Angeles address, the Board held that the MPN agreement did not restrict treatment to that specific location or Tax ID. Therefore, the WCJ's determination that applicant was entitled to treat outside the MPN due to notice deficiencies was not reconsidered, as the treatment was deemed within the network.

MPNAD Rule 9767.12Labor Code section 3550Medical Provider NetworkWCJPetition for ReconsiderationWellCompCFMCTax IDlien claimant
References
Case No. ADJ11059073
Regular
Jan 17, 2023

SHERRILL CLAYTOR vs. ALEXANDER R. LATTERI, M.D., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision allowing the applicant to treat with Dr. Spencer outside the defendant's Medical Provider Network (MPN). The WCAB found insufficient evidence that Dr. Spencer, or the applicant's previously selected physician Dr. Small, were definitively part of the defendant's MPN at the time of the request. Therefore, without proper MPN notification and an established denial of care, the applicant retained the right to resume treatment with her non-MPN physician, Dr. Spencer. The defendant may still attempt to transfer the applicant's care into the MPN by following proper statutory procedures.

MPNPTPmedical provider networkprimary treating physicianreconsiderationfindings and ordertransfer of caredenial of caresubstantial evidenceadministrative director rules
References
Case No. ADJ15777619, ADJ15777625
Regular
Oct 13, 2025

VIRGINIA GALVAN vs. REGIONAL CENTER OF ORANGE COUNTY, INC.; CYPRESS INSURANCE COMPANY

Defendant sought reconsideration of the Joint Findings and Order issued on August 12, 2025, which found applicant sustained an employment-related injury and could self-procure treatment outside the defendant's medical provider network (MPN). Defendant contended the applicant failed to establish a neglect or refusal to provide reasonable medical care and that the WCJ's order allowing treatment outside the MPN was unsupported. The Appeals Board, after considering the petition, answer, and the WCJ's report, denied reconsideration. The Board adopted and incorporated the WCJ's findings that defendant failed to provide evidence of a valid MPN, proper notices, or treatment within the MPN, thereby constituting a denial of medical care and allowing the applicant to treat outside the MPN.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Findings and OrderMedical Provider Network (MPN)Self-Procure TreatmentNeglect or Refusal to TreatAdverse InferencePre-Trial Conference Statement (PTCS)Discovery ClosureMandatory Settlement Conference (MSC)
References
Case No. ADJ9687796
Regular
Mar 23, 2015

MOHAMMAD RAFIQ vs. VILLAGE NURSERIES, APPLIED RISK

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration. The applicant sought treatment outside the defendant's Medical Provider Network (MPN), arguing the MPN lacked toxicologists. The judge found the applicant was not entitled to out-of-MPN treatment as they were not treating with a toxicologist and the MPN had sufficient internal medicine physicians. The applicant also failed to prove medical necessity for a toxicologist through treating physician reports.

Workers' Compensation Appeals BoardPetition for ReconsiderationDeniedMPNLabor Code §4616(a)Cal. Code of Reg. §9767.5Medical TreatmentSelf-Procured Medical TreatmentToxicologistInternal Medicine
References
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