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

Case No. MISSING
Regular Panel Decision
Sep 04, 2013

Matter of Madigan v. ARR ELS

In 1994, the claimant sustained a low back injury during employment as a machinist, leading to workers' compensation benefits. Liability for the case was transferred to the Special Fund for Reopened Cases in 2003. Due to poor surgical outcomes, the claimant has been on pain medication, including oxycontin, since at least 2007, with doses escalating. A consultant for the Special Fund questioned the necessity of the increased medication, prompting a hearing. A Workers’ Compensation Law Judge ruled that the pain medications should continue, with the Special Fund covering the costs, until new Board guidelines or physician recommendations advised otherwise. The Workers’ Compensation Board affirmed this decision, citing that their Medical Treatment Guidelines for chronic pain were still in draft form at the time. The appellate court subsequently affirmed the Board's decision, noting that the guidelines were not yet in effect at the time of the Board's ruling and that the Board's interim guidance was rational.

Workers' CompensationPain ManagementOpioid PrescriptionsMedical Treatment GuidelinesSpecial FundReopened CasesLumbar InjuryOxycontinAppellate ReviewAdministrative Law
References
4
Case No. MISSING
Regular Panel Decision

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
Case No. 526425
Regular Panel Decision
Nov 15, 2018

Matter of Gasparro v. Hospice of Dutchess County

Mary Ann Gasparro, a claimant with a permanent partial disability from a 1995 work injury, moved to Nevada. In 2016, her employer's workers' compensation carrier objected to payments for topical pain relief products, LidoPro and Terocin patches, prescribed by a Nevada pain management specialist. The Workers' Compensation Board reversed a Workers' Compensation Law Judge's ruling, deciding that New York's Medical Treatment Guidelines apply to out-of-state treatment for nonresident claimants, a departure from its prior decisions. The Board found the prescribed medications were not in accordance with the guidelines due to concomitant use and duration. The Appellate Division, Third Department, affirmed the Board's decision, deeming its change in course rational and its application of the guidelines to out-of-state treatment reasonable. The court concluded that the Board's finding of medical necessity and non-compliance with guidelines was supported by substantial evidence.

Workers' CompensationMedical Treatment GuidelinesOut-of-State Medical CareNonresident ClaimantsPain ManagementTopical Pain ReliefLidoProTerocin PatchesAppellate DivisionBoard Reversal
References
12
Case No. 2020 NY Slip Op 03966 [185 AD3d 1263]
Regular Panel Decision
Jul 16, 2020

Matter of McKay v. Southampton Hosp.

The case concerns an appeal by Jacqueline McKay (claimant) from a Workers' Compensation Board decision. The Board had affirmed a Workers' Compensation Law Judge (WCLJ) ruling to consider weaning the claimant from opioid medications based on an independent medical examiner's opinion under the Non-Acute Medical Treatment Guidelines (NAPMTG). The claimant argued that the Board exceeded its authority in promulgating these guidelines. The Appellate Division, Third Department, affirmed the Board's decision, holding that the Board properly exercised its broad regulatory power under the Workers' Compensation Law to issue the NAPMTG. The court found the guidelines rational and not unreasonable, arbitrary, capricious, or contrary to the statute, emphasizing that the NAPMTG furthered the aim of ensuring prompt and appropriate medical care for injured workers by expanding existing treatment guidelines to address comprehensive pain management, including the safe use of narcotics.

Medical Treatment GuidelinesOpioid WeaningRegulatory AuthorityAdministrative LawAppellate ReviewPain ManagementOccupational DiseasePermanent Partial DisabilityWorkers' Compensation BoardIndependent Medical Examination
References
5
Case No. MISSING
Regular Panel Decision

Claim of Kigin v. State of New York Workers' Compensation Board

In 1996, claimant sustained work-related injuries, leading to workers' compensation benefits and a classification of permanent partial disability in 2006. Her treating physician, Andrea Coladner, requested a variance for additional acupuncture treatments beyond the scope of the Workers' Compensation Board's Medical Treatment Guidelines, which went into effect in 2010. The Special Fund for Reopened Cases denied the variance based on an independent medical examination by Peter Chiu, citing a lack of objective findings. A Workers' Compensation Law Judge and the Board affirmed this denial, prompting the claimant's appeal. The court affirmed the Board's decision, holding that the Board lawfully promulgated the Guidelines to predetermine medical necessity and that the variance procedure, which shifts the burden of proof to claimants for treatments outside the Guidelines, is permissible and consistent with due process.

Workers' CompensationMedical Treatment GuidelinesAcupunctureVariance RequestPermanent Partial DisabilityMedical NecessityBurden of ProofDue ProcessStatutory InterpretationAdministrative Law
References
19
Case No. ADJ2068970 (STK 0167616)
Regular
Jul 21, 2016

Norman McAtee vs. Briggs & Pearson Construction, State Compensation Insurance Fund

The applicant seeks reconsideration of a WCJ's decision that dismissed his appeal of an Independent Medical Review (IMR) determination regarding pain medication. The IMR found the medication medically unnecessary, but the applicant argues this was based on a plainly erroneous finding of fact regarding the applicable treatment guidelines. The Appeals Board granted reconsideration, finding the IMR determination was indeed based on a plainly erroneous interpretation of the medical treatment guidelines. Consequently, the Board rescinded the WCJ's decision and remanded the case for a new IMR by a different reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewPlainly Erroneous Finding of FactLabor Code Section 4610.6Medical Treatment GuidelineOpioid TherapyPermanent DisabilityVocational RehabilitationAdministrative Law JudgeReconsideration
References
1
Case No. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. WCB No. 7990 5338
Regular Panel Decision

In the Matter of Maureen Kigin v. State of New York Workers' Compensation Board

Justice Rivera's dissenting opinion argues that the Workers’ Compensation Board overstepped its authority by implementing regulations that demand preapproval for medical services not listed in its guidelines, thereby presuming such unlisted treatments are not medically necessary. This approach, according to the dissent, obstructs prompt medical care, contradicts the Workers’ Compensation Law's pro-employee stance, and deviates from the legislative intent to ease access to diagnostic and treatment measures. The opinion contends that while the Board can create a pre-authorized list, it cannot use this power to impose a burden on claimants like Kigin to continually prove the medical necessity of treatments not on that list, especially when disputes historically allowed for post-treatment resolution.

Workers' Compensation LawMedical Treatment GuidelinesPre-authorization RegulationsVariance SchemeMedical NecessityBoard AuthorityAdministrative RegulationsClaimant Burden of ProofStatutory InterpretationLegislative Intent
References
13
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
10
Case No. MISSING
Regular Panel Decision

Lutheran Medical Center v. Hereford Insurance

Maher Kiswani, a livery car driver, was injured in an automobile accident and received medical treatment from Lutheran Medical Center. Lutheran, as Kiswani's assignee, sought payment from Hereford Insurance Company, the no-fault carrier, which refused to pay. After an initial arbitration where the Workers' Compensation Board determined Kiswani was not injured in the course of employment (without Hereford's notice), a second arbitration awarded Lutheran no-fault benefits. The Supreme Court, Kings County, vacated this arbitration award, ruling that Hereford should have been notified of the Workers' Compensation Board hearing. The appellate court affirmed the Supreme Court's decision, holding that a party not afforded an opportunity to participate in a Board hearing is not bound by its determination.

Arbitration AwardNo-Fault InsuranceWorkers' Compensation BoardDue ProcessNotice RequirementsVacated Arbitration AwardAppellate ReviewLivery Car DriverAutomobile AccidentMedical Benefits
References
3
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