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Case Law Database

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

Case No. ADJ9694948
Regular
Feb 01, 2016

ESTHER SANDOVAL vs. SAN DIEGO UNIFIED SCHOOL DISTRICT, YORK RISK SERVICES GROUP

The Workers' Compensation Appeals Board denied San Diego Unified School District's petition for reconsideration of an award finding applicant entitled to right shoulder surgery. The defendant argued that the medical opinions supporting the surgery were not substantial evidence because they didn't cite MTUS/ACOEM guidelines or explain non-compliance. The Board affirmed the original finding, agreeing with the WCJ that citing the MTUS is not strictly required if the medical evidence is otherwise compelling and consistent with the guidelines. While one commissioner concurred, he disagreed with the majority's assertion that MTUS citation is not necessary for compliance with Labor Code section 4604.5.

Workers' Compensation Appeals BoardSan Diego Unified School DistrictYork Risk Services GroupPetition for ReconsiderationFindings Award and OrderIndustrial InjuryFurther Medical TreatmentRight Shoulder SurgeryMedical Treatment Utilization ScheduleACOEM guidelines
References
0
Case No. ADJ8286511
Regular
May 30, 2017

HECTOR SANCHEZ BARRAGAN vs. T&T MARKETING SERVICES, INC., STATE COMPENSATION INSURANCE FUND

This case concerns the applicant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision that upheld an Independent Medical Review (IMR) denial of a Norco prescription. The applicant argued the IMR determination exceeded the Administrative Director's authority due to a plainly erroneous application of Medical Treatment Utilization Schedule (MTUS) guidelines. The WCAB denied the petition, adopting the trial judge's report which found the IMR reviewer correctly applied medical expertise to select relevant MTUS sections for chronic opioid use. The Board determined the applicant failed to provide clear and convincing evidence of erroneous MTUS application or that the IMR decision was otherwise invalid.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardIndependent Medical ReviewUtilization ReviewNorcoMedical Treatment Utilization ScheduleAdministrative DirectorLabor CodeChronic Pain Medical Treatment Guidelines
References
1
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
2
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
9
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
0
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
1
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
4
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
9
Case No. MISSING
Regular Panel Decision

Refined Sugars, Inc. v. Local 807 Labor-Management Pension Fund

This case involves Refined Sugars, Inc. (RSI) challenging a withdrawal liability claim brought by the Local 807 Labor-Management Pension Fund and its Board of Trustees under ERISA and MPPAA. RSI filed for a declaratory judgment, arguing it was not an 'employer' subject to such liability. The court analyzed the definition of 'employer' under ERISA Title IV and Title I, concluding that RSI did not meet the criteria, particularly regarding common control with the direct employer, Francrete Corporation. Additionally, the court rejected the application of common law criteria and the joint employer theory. Consequently, RSI's motion for summary judgment was granted, and the defendants' cross-motion was denied, finding RSI not liable for withdrawal contributions.

ERISAMPPAAWithdrawal LiabilityMulti-employer Pension PlanSummary JudgmentEmployer DefinitionCommon ControlIndependent ContractorJoint EmployerPension Fund
References
10
Case No. MISSING
Regular Panel Decision

Cantwell v. Secretary of Department of Health & Human Services of United States

Margaret Cantwell sought judicial review of a final determination by the Secretary of Health and Human Services, which denied her application for disability insurance benefits. Cantwell, born in 1930 and with a background in the insurance industry, alleged disability commencing in July 1982 due to arthritis, chest pains, high blood pressure, headaches, and nervousness. An Administrative Law Judge found her not disabled, a decision affirmed by the Appeals Council on March 4, 1985. However, the court noted that the Appeals Council's approval occurred after the enactment of the Social Security Disability Benefits Act of 1984, which established a moratorium on mental impairment reviews and mandated the application of revised criteria. Considering Cantwell's mental and emotional condition, the court remanded the case to the Secretary with instructions to redetermine her disability application using the revised criteria for mental impairments.

disability benefitssocial security actmental impairmentremandadministrative law judgeappeals councilsocial security disability benefits act of 1984revised criteriasubstantial evidencemedical evidence
References
2
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