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

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. ADJ339088 (SDO 0304788)
Regular
Aug 30, 2016

Gregory Parrent vs. SBC-PACIFIC BELL TELEPHONE COMPANY

This case clarifies the utilization review (UR) and independent medical review (IMR) process for medical treatment recommendations within a Medical Provider Network (MPN). The Appeals Board affirmed that even when a physician is part of the defendant's MPN, their treatment recommendations are subject to UR by the employer if disputed. If UR denies or modifies the recommendation, the dispute must then proceed to IMR, not the Appeals Board. The applicant's contention that MPN physicians' recommendations are exempt from UR was rejected, emphasizing a uniform standard of care and review for all medical treatment.

Workers' Compensation Appeals BoardSBC-Pacific Bell Telephone CompanySedgwick Claims Management ServicesPetition for ReconsiderationMedical Provider Network (MPN)Independent Medical Review (IMR)Utilization Review (UR)Labor Code section 4600primary treating physicianRequest for Authorization (RFA)
References
5
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. ADJ 2302916
Regular
Nov 15, 2010

MANUEL CARDOZA vs. CORSICAN FURNITURE, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the lien claimant's petition for reconsideration. The lien claimant sought payment for medical devices provided to the applicant, arguing the treatment was reasonable and the employer improperly handled utilization review. The Board found the lien claimant failed to meet its burden of proof by submitting a prescription that did not meet the statutory standards for a medical report. Furthermore, the request for authorization for treatment was not in the proper format to trigger utilization review.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantFindings of Fact and OrderWCJLabor Code section 4600Labor Code section 4610Utilization ReviewMedical TreatmentReasonable Value
References
4
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. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
Case No. ADJ9469994
Regular
May 28, 2019

Jose Mejia vs. E.T. SECURITY, STATE COMPENSATION INSURANCE FUND

This case involves a lien claim by National Script Pharmacy for $16,453.92 in compound medications. The Administrative Law Judge initially disallowed the lien, finding the claimant failed to prove the medications were reasonable and necessary. The Appeals Board rescinded this decision, remanding the case to the trial level. This is because the parties need to address the applicability of the Medical Treatment Utilization Standards (MTUS) to the prescribed compound medications, and whether the documentation adequately supported their necessity under these standards.

Workers' Compensation Appeals BoardReconsiderationLien ClaimantCompound MedicationsUtilization ReviewMedical Treatment Utilization StandardsReasonable and NecessaryBurden of ProofPrimary Treating PhysicianPanel Qualified Medical Evaluator
References
6
Case No. ADJ3781289 (MON 0347653)
Regular
Jan 06, 2012

Margaret Batten vs. Long Beach Memorial Medical Center, TRISTAR RISK MANAGEMENT

The Workers' Compensation Appeals Board granted reconsideration to amend a prior award. The Board affirmed the finding that the defendant unreasonably delayed medical treatment for the applicant's neck, noting the defendant failed to follow proper utilization review procedures. However, the Board deferred the award of medical treatment for the applicant's ankle, as a determination of industrial causation for that body part was still pending. The decision specifically mentions the defendant's adjuster's testimony disputing an AME's finding of industrial injury to the cervical spine.

WCABLong Beach Memorial Medical CenterTristar Risk Managementunreasonable delaymedical treatmentorthoticsnecklumbar sacral spinepsycheankle
References
5
Case No. ADJ1635860 (ANA 0371188) ADJ3803325 (ANA 0371189)
Regular
Feb 20, 2018

SHERRY HOUGH vs. COOPERVISION, EMPLOYERS INSURANCE OF WAUSAU

This case involves an applicant seeking workers' compensation benefits for medical treatment recommended by her physician. The defendant contested responsibility, arguing a 2016 motor vehicle accident was the sole proximate cause of the need for treatment, not the applicant's 2002 industrial injury. The Board affirmed the finding that the treatment was at least partially related to the industrial injury but amended the order. This amendment defers the determination of medical necessity for the requested treatment pending further development of the record. Crucially, the defendant was precluded from utilizing the utilization review process due to their failure to properly notify the applicant and her attorney of their deferral decision.

Workers' Compensation Appeals BoardReconsiderationJoint Findings and OrderRequest for Authorization (RFA)Utilization Review (UR)Intervening CauseProximate CauseAgreed Medical Examiner (AME)Causally RelatedCumulative Trauma
References
5
Case No. ADJ21 45168 (GOL 0096589)
Regular
Sep 20, 2016

THOMAS HOGENSON vs. VOLKSWAGEN OF AMERICA, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

This case concerns whether medical treatment proposed by an injured worker's physician, chosen from the employer's Medical Provider Network (MPN), is subject to Utilization Review (UR) and Independent Medical Review (IMR). The Workers' Compensation Appeals Board (WCAB) rescinded the administrative law judge's award of treatment, holding that MPN treatment is indeed subject to UR and IMR. The WCAB clarified that statutory provisions for UR and IMR apply to all medical treatment disputes, regardless of whether the physician is within an MPN. The matter was returned to the trial level for further proceedings consistent with this decision.

Workers' Compensation Appeals BoardThomas HogensonVolkswagen of AmericaInsurance Company of the State of PennsylvaniaExpedited Findings Of Fact And AwardUtilization ReviewMedical Provider NetworkIndependent Medical ReviewMedical TreatmentLabor Code
References
13
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