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

Case No. ADJ3934515 (MON 0271347) ADJ4001097 (LAO 0780370)
Regular
Feb 16, 2017

PRISCILLA DIAZ vs. PUBLIC HEALTH FOUNDATION ENTERPRISES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied Dr. David Silver's Petition for Reconsideration. The Board affirmed the Administrative Law Judge's finding that the lien claimant take nothing on his lien. This was based on the lien claimant's failure to meet his burden of proof that the services rendered were reasonable and necessary for the applicant's industrial injury. Furthermore, the lien claimant failed to adequately establish the costs of his services with sufficient supporting evidence.

Lien claimantPetition for ReconsiderationJoint Findings and OrderWorkers' Compensation Appeals BoardAdministrative Law Judgemedically necessaryburden of proofsubstantial evidenceLabor Code section 4903.8(d)reasonable and necessary medical treatment
References
Case No. ADJ1560752
Regular
Sep 09, 2025

EUGENE FLOWERS vs. RAY MAC PAINTING, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed the January 12, 2021 Findings and Award (F&A) in the case of Eugene Flowers, who sustained an industrial injury to his right shoulder and subsequently alleged a psyche injury. Defendant State Compensation Insurance Fund sought reconsideration, contesting the reasonableness of treatment provided by lien claimant Behavioral Medicine and Health Psychology, liability for statutory increase and interest, and the validity of the lien due to declaration requirements. The WCAB, adopting the WCJ's report, concluded that the applicant's psyche injury was a compensable consequence, the psychological treatment was medically necessary and reasonable, and the lien was not barred by the late filing of the declaration under Labor Code section 4903.8(d). Consequently, the F&A, which ordered payment for adjusted charges along with statutory interest and increase, was upheld.

ReconsiderationFindings and AwardBehavioral Medicine and Health Psychologyindustrial injurypsychemedically reasonablenecessarystatutory increaseinterestlien claimant
References
Case No. SAC 286368
Regular
Jan 25, 2008

DALE OLIVER vs. BRIAN WILLIAMS CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking approval for disc replacement surgery for a work-related back injury. The defendant argued the surgery is experimental per ACOEM guidelines, thus not covered. The Board denied reconsideration, finding the applicant's physician rebutted the presumption of experimental status. The Board determined the surgery is no longer experimental, citing FDA approval, and is reasonably required for the applicant's specific condition, supported by expert medical opinion.

Workers' Compensation Appeals BoardBrian Williams ConstructionState Compensation Insurance Fundindustrial injuryright anklefootelbowshoulderskneesleft lower extremity
References
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. ADJ10933682
Regular
Dec 04, 2020

AMY LI vs. KAISER PERMANENTE, SEDGWICK CMS

This case involves a petition for reconsideration by Essential Interpreting Inc. (cost petitioner) concerning its claim for deposition preparation interpreting services. The Workers' Compensation Appeals Board denied the petition, affirming the administrative law judge's finding that the cost petitioner failed to prove its services were reasonable and necessary under Labor Code section 5811. The defendant, Kaiser Permanente, had specifically stated in its deposition notice that it would provide the interpreter for both preparation and deposition time. Since the cost petitioner did not demonstrate why using an interpreter of its choosing was necessary over the one provided by the defendant, their claim for reimbursement was denied.

WCABPetition for ReconsiderationLabor Code Section 5811Labor Code Section 5813deposition preparationinterpreting servicescost petitionerapplicantdefendantWCJ
References
Case No. ADJ9542328
Significant
Nov 14, 2019

Ashley Colamonico vs. Secure Transportation, National Union Fire Insurance Company, Administered by SEDGWICK CMS

This en banc decision clarifies that a medical-legal provider bears the initial burden of proof to show that its expenses were reasonable and necessary at the time they were incurred, and a defendant does not waive these objections by failing to raise them in a timely Explanation of Review (EOR).

En bancPetition for ReconsiderationMed-Legal Photocopylien claimantexplanation of reviewcontested claimreasonable and necessarysubpoena duces tecumburden of proofmedical-legal expenses
References
Case No. GRO 0031810
En Banc
Nov 13, 2007

Joey M. Costa vs. Hardy Diagnostic, State Compensation Insurance Fund

The Appeals Board affirmed its prior decision, holding that Labor Code section 4660 allows parties to present rebuttal evidence to a permanent disability rating under the new PDRS, and the reasonable and necessary costs for such evidence, like vocational expert testimony, may be allowable under section 5811.

PDRSSB 899vocational rehabilitationexpert witnessrebuttal evidencepermanent disability ratingLabor Code section 5811medical-legal costsreasonable and necessaryWCJ
References
Case No. GRO 0032183
Regular
Mar 18, 2008

RIGOBERTO GARCIA vs. DALE HAMPTON, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board affirmed a finding of fact denying reimbursement for Wallace & Associates' bill. Applicant failed to prove that these services were reasonable and necessary for his case, as required by Labor Code section 5811 and established precedent. Therefore, the applicant bears the burden of proof for such costs, which was not met.

Workers' Compensation Appeals BoardPetition for ReconsiderationIndustrial InjuryCompromise and ReleaseFinding of FactLabor Code section 5811Reimbursement of CostsPermanent Disability RatingCosta v. Hardy DiagnosticReasonable and Necessary
References
Case No. WCK 0068261
Regular
Dec 11, 2007

BECKIE CARTER vs. ADVANCE COMMUNICATIONS CENTER, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration of a decision that reinstated an earlier finding dismissing a lien claimant's claim. The lien claimant argued their treatment was reasonably necessary despite a Utilization Review physician's testimony and adherence to specific guidelines. The Board adopted the WCJ's report, denying the petition and upholding the dismissal of the lien.

Lien claimantReconsiderationUtilization ReviewWCJReasonably necessaryCure or relieveIndustrial injuryCompromise and ReleaseACOEM GuidelinesChronic pain
References
Case No. ADJ3357881
Regular
Apr 06, 2012

HELEN DEMBY vs. MAXIM HEALTHCARE SERVICES, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

The Workers' Compensation Appeals Board granted reconsideration, rescinding a previous award. The Board found that medical treatment provided by True Sleep LLC was not reasonable or necessary for the applicant's industrial injury. This decision was based on the lack of substantial medical evidence linking the treatment to the applicant's admitted back injury, and no evidence establishing a separate industrial sleep injury.

Workers' Compensation Appeals BoardHelen DembyMaxim Healthcare ServicesInsurance Company of the State of PennsylvaniaESISADJ3357881LAO 0874404Petition for ReconsiderationFindings and AwardWCJ
References
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