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

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. ADJ6989761
Regular
Sep 30, 2013

ELVIN SALGUERO vs. CHARLES GEMEINER CABINETS, INSURANCE COMPANY OF THE WEST

This case involves an applicant seeking reconsideration of a denial for 24/7 home care. The applicant argues the denial was an abuse of discretion, as medical evidence supported the need for such care due to suicidal ideation and depression. The Workers' Compensation Appeals Board denied the petition, adopting the judge's report which found no support for 24/7 home care in relevant treatment guidelines. The judge concluded that the applicant failed to prove the requested care was reasonable and necessary beyond the requirements of existing guidelines.

WCABPetition for ReconsiderationHand Surgery EvaluationStellate Block ProceduresHome CarePsychiatric TechnicianLicensed Vocational NurseSuicidal IdeationPsychiatric HospitalizationLabor Code Section 4600(b)
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. 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. ADJ8115084
Regular
Jun 02, 2014

MARY HAYWORTH vs. KCI HOLDINGS USA, INC., FIDELITY AND GUARANTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, rescinding a prior finding that the applicant failed to establish a plainly erroneous fact in an Independent Medical Review (IMR) determination. The Board found the IMR decision was based on a plainly erroneous mistake of fact because it evaluated a request for dorsal medial branch block injections as though it were a request for facet injections, which are different procedures. Consequently, the medical treatment dispute is remanded to the Administrative Director for review by a different independent review organization or reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.5Plainly Erroneous Finding of FactMedical Treatment DisputeUtilization ReviewAdministrative DirectorDorsal Medial Branch BlockFacet InjectionsMTUS Guidelines
References
Case No. ADJ9197803
Regular

CHRISTOPHER TORRES vs. CONTRA COSTA SCHOOLS INSURANCE GROUP, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied Christopher Torres's petition for reconsideration of an Independent Medical Review (IMR) determination. The Board found that the applicant failed to prove, by clear and convincing evidence, any of the limited grounds for appeal specified in Labor Code section 4610.6(h). Specifically, the Board agreed with the WCJ that whether the IMR reviewer correctly applied medical guidelines involves expert opinion, not a matter of ordinary knowledge. Therefore, the Board upheld the IMR decision.

WCABPetition for ReconsiderationLabor Code Section 4610.6Administrative DirectorMedical ReviewIndependent Medical Reviewer (IMR)MTUS guidelinesACOEM guidelinesClear and convincing evidencePlainly erroneous finding of fact
References
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
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. 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
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