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

Case No. ADJ10555511
Regular
Oct 03, 2018

MARIO GUDINO IBARRA vs. ASHLEY FURNITURE INDUSTRIES, INC., HARTFORD INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC.

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, ruling that Truxtun Pharmacy failed to meet its burden of proof for reimbursement of its lien. The Board found that the pharmacy did not provide substantial medical evidence demonstrating the compound medications were reasonable and necessary under the Medical Treatment Utilization Schedule (MTUS). Specifically, the physician's report lacked necessary citations and the prescribed treatments were not recommended by the MTUS. Therefore, the lien claimant is entitled to no recovery on its lien.

Workers Compensation Appeals BoardAshley Furniture IndustriesHartford Insurance CompanyGallagher Bassett ServicesMario Gudino IbarraTruxtun PharmacyMedical Treatment Utilization ScheduleMTUSOfficial Medical Fee ScheduleOMFS
References
Case No. ADJ10373550
Regular
Apr 25, 2019

EVALINA AGUILAR-RIVAS vs. K&H SUBWAY, INC., dba AAA SUBWAY INVESTMENT GROUP, INC.; EMPLOYERS ASSURANCE COMPANY

The Workers' Compensation Appeals Board affirmed a prior decision denying recovery for three lien claimants: Kohanim Chiropractic, Metropolitan Health Group, and SoCal Interpreting. The lien claimants failed to prove their medical services or interpreting services were reasonable and necessary under the Medical Treatment Utilization Schedule (MTUS), as required by Labor Code section 5402(c). Specifically, they did not demonstrate that the treatment was consistent with MTUS guidelines or that interpreter invoices were properly submitted to the defendant. Therefore, the Board concluded the lien claimants did not meet their burden of proof for reimbursement.

WCABReconsiderationLien ClaimantsMedical-Legal CostsSelf-Procured TreatmentLabor Code Section 5402(c)Utilization ReviewDelay PeriodBurden of ProofMedical Treatment Guidelines
References
Case No. ADJ6766619 (MF) ADJ6766620
Regular
Feb 28, 2018

MARIA DURAN vs. FOREVER 21 RETAIL, INC., CHUBB GROUP

This case involves Maria Duran's request for home health care services, which was initially denied by utilization review (UR) and upheld by Independent Medical Review (IMR). The applicant argued that her need for assistance with household chores and personal hygiene fell outside the scope of the Medical Treatment Utilization Schedule (MTUS) guidelines as applied. While the Board acknowledges that the specific MTUS guideline used in this case was later found to be an invalid regulation in a related case, it affirmed the original decision. This affirmance was based on the finding that the initial request for services was too vague, lacking specific details on the type, frequency, and duration of care, and that a revised request could be made.

Workers' Compensation Appeals BoardMaria DuranForever 21 RetailInc.Chubb GroupOpinion and Decision After ReconsiderationIndependent Medical ReviewIMRUtilization ReviewUR
References
Case No. ADJ9046738
Regular
Oct 03, 2025

Arnoldo Galvan vs. Donaghy Sales, LLC., Sentinel Insurance Company, Ltd, Gallagher Bassett

The applicant, Arnoldo Galvan, sustained a cumulative trauma during his employment. The defendant, Donaghy Sales, LLC, along with its insurer Sentinel Insurance Company, Ltd., and administrator Gallagher Bassett, failed to provide the correct fax number for Request for Authorization (RFA) forms to utilization review for treating physician Dr. William Foxley. The Workers' Compensation Appeals Board (WCAB) has granted the defendant's petition for reconsideration of the June 30, 2025 Findings of Fact, Award, and Orders. The WCAB found that the record was not sufficiently developed regarding the timeliness of UR determinations and the application of the Medical Treatment Utilization Schedule (MTUS). Consequently, a final decision after reconsideration has been deferred for further review of the factual and legal issues.

Request for AuthorizationUtilization ReviewClaims AdministratorFindings of FactPetition for ReconsiderationRemovalMedical TreatmentWCJSanctionsMedical Necessity
References
Case No. ADJ15329380
Regular
Oct 31, 2025

BERTHA VALERIO vs. KIMCO STAFFING SERVICES, INC.; XL INSURANCE

Defendant sought reconsideration of a Findings and Award (F&A) from August 5, 2025, concerning an injury sustained by applicant Bertha Valerio on September 9, 2021. The F&A found that applicant's injury was AOE/COE, defendant failed to prove improper treatment outside the Medical Provider Network (MPN), and lien claimant Joyce Altman Interpreting, Inc. established their market rate for interpreting services. Defendant contended that medical treatment and interpreter services were unreasonable due to treatment outside the MPN and failure to adhere to MTUS/ACOEM guidelines, and that the market rate for interpreter services was not properly established. The Appeals Board denied the petition, agreeing with the WCJ that defendant failed to sustain its burden of proof on the MPN issue, the MTUS/ACOEM guideline issue was not raised at trial, and lien claimant properly established their market rate.

WCABPetition for ReconsiderationFindings and AwardMedical Provider NetworkMPNRequests for AuthorizationRFAsLien ClaimantMarket RateLabor Code Section 4600
References
Case No. ADJ8100720
Regular
Dec 03, 2018

CELIA PEREZ DE PRECIADO vs. ROSS STORES, INC., SEDGWICK CLAIMS MANAGEMENT SERVICES

The applicant sought reconsideration of a denial of home health care services, arguing the Medical Treatment Utilization Standards (MTUS) did not apply to her requested assistance. The Appeals Board found the 2009 MTUS guideline used in the initial denial was an invalid regulation. Consequently, the Board rescinded findings that the Administrative Director acted within authority and that the determination was not plainly erroneous. The matter is returned for further proceedings, including a new Independent Medical Review, to properly assess the applicant's claim.

Workers' Compensation Appeals BoardIndependent Medical Review (IMR)Utilization Review (UR)Medical Treatment Utilization Standards (MTUS)Home Health CareActivities of Daily Living (ADLs)Labor Code section 4600(h)Plainly Erroneous FindingsAdministrative Director (AD)Void Ab Initio
References
Case No. ADJ1429214 (LAO 0753357)
Regular
Sep 21, 2018

ELIAZAR ACEVEDO vs. SPIENELLO CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involved an applicant's appeal of an Independent Medical Review (IMR) decision that denied home health care services, arguing the MTUS guidelines were erroneous. The applicant sought reconsideration of the WCJ's denial, claiming the MTUS conflicted with Labor Code section 4600 by requiring a homebound status. However, the applicant subsequently reached a settlement with the defendant on all outstanding issues. Therefore, the Appeals Board dismissed the applicant's Petition for Reconsideration and returned the matter to the trial level to finalize the settlement.

Eliazar AcevedoSpinello ConstructionState Compensation Insurance FundADJ1429214LAO 0753357Opinion and Decision After ReconsiderationPetition for ReconsiderationIndependent Medical Review (IMR)Home Health Care ServicesMedical Treatment Utilization Standards (MTUS)
References
Case No. ADJ10917168 (MF)
Regular
Oct 21, 2019

JACOB PIKE vs. CITY OF LONG BEACH

This case concerns an applicant seeking reconsideration of a Workers' Compensation Appeals Board decision denying a right knee meniscal transplantation. The judge found the requested treatment did not fall within presumptively correct Medical Treatment Utilization Standards (MTUS) or present sufficient scientific evidence to rebut the presumption. Applicant argued the physician's report constituted scientific evidence and supported medical necessity, but the Board affirmed the denial. The Board found the applicant failed to meet the burden of proof by a preponderance of scientific medical evidence for treatment outside MTUS guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Findings of Factindustrial injuryright knee meniscal transplantationUtilization Review (UR)Medical Treatment Utilization Standards (MTUS)Labor Code sections 4604.55307.27medically necessary
References
Case No. ADJ1798944 (LBO 0326931)
Regular
Jun 13, 2018

MARIA FIGUEROA vs. HELP NET, INC., STATE COMPENSATION INSURANCE FUND

This case concerns a lien claimant's petition for reconsideration of a WCJ's decision disallowing his lien for chiropractic services provided between 2001 and 2005. The Appeals Board rescinded the WCJ's decision, finding the claimant's petition timely due to defective service. Crucially, the Board determined that the Medical Treatment Utilization Schedule (MTUS) was improperly applied; instead, the American College of Occupational and Environmental Medicine (ACOEM) guidelines, in effect during the treatment period, should govern the determination of reasonable and necessary care. The matter is remanded to the WCJ for further proceedings consistent with the ACOEM guidelines.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and OrderMedical Treatment Utilization Schedule (MTUS)American College of Occupational and Environmental Medicine (ACOEM)Labor Code Section 4600(b)SB 899Compromise and ReleaseAgreed Medical Examiner (AME)
References
Case No. ADJ10127986
Regular
May 28, 2019

SAMANTHA SILVA vs. HILMAR CHEESE, SAFETY NATIONAL INSURANCE

This case concerns the compensability of Voltaren gel prescribed for the applicant's bilateral hand, wrist, and trigger finger injuries. The Workers' Compensation Appeals Board granted reconsideration, rescinding the original findings. The Board found that the critical issue was whether the generic equivalent of Voltaren gel was exempt from utilization review (UR), not solely the brand name's formulary status. The matter was returned for further proceedings to clarify the issues and for a new decision on the eligibility of the generic Voltaren gel.

Workers' Compensation Appeals BoardUtilization ReviewMedical Treatment Utilization ScheduleMTUSDrug FormularyExempt DrugGeneric DrugBrand Name DrugVoltaren GelFindings of Fact
References
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