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Case Law Database

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

Case No. ADJ873701 (ANA 0299104) ADJ1741214 (ANA 0299113)
Regular
Sep 04, 2018

SHELLEE SMITH vs. SMITH'S FOOD AND DRUG, a subsidiary of the Kroger Company, permissibly self-insured, administered by SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves an untimely denial of a request for zolpidem by the defendant employer. The Workers' Compensation Appeals Board (WCAB) granted reconsideration because the trial judge's decision on medical necessity lacked substantial evidence due to a missing medical report. The matter is returned to the trial level to determine the reasonableness and necessity of the zolpidem treatment based on the correct evidence. The WCAB clarified that even with an untimely denial, the applicant must still prove the medical necessity of the requested treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardZolpidemUtilization ReviewIndependent Medical ReviewRequest for AuthorizationUntimely DenialMedical NecessityBurden of Proof
References
4
Case No. ADJ6444600
Regular
Jan 22, 2020

PAUL AGUILAR vs. CITY OF LOS ANGELES

This case involved a dispute over the timeliness of a utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, finding the original WCJ erred by concluding the UR denial was untimely solely due to lack of telephone/fax communication. While the WCAB agreed the UR denial was untimely because it wasn't communicated to the physician as required by law, it found the record incomplete regarding the medical necessity of the treatment. Therefore, the WCAB rescinded the order authorizing treatment and returned the matter to the WCJ for further proceedings to determine medical necessity.

Utilization ReviewRequest for AuthorizationTimelinessCommunicationProspective TreatmentLabor Code Section 4610Administrative Director RuleBodam v. San Bernardino CountyMedical NecessitySubstantial Evidence
References
9
Case No. ADJ4523909
Regular
Mar 04, 2016

GLORIA BLACKMON vs. ABZ AUTO WRECKAGE, TRUCK INSURANCE COMPANY, FARMERS INSURANCE EXCHANGE

This case concerns an applicant's petition for reconsideration of a denial of medical treatment authorization. The Workers' Compensation Appeals Board (WCAB) denied the petition, upholding the administrative law judge's decision. The key issue was whether an untimely Independent Medical Review (IMR) determination invalidates the IMR process, thereby allowing the WCAB to decide treatment necessity. The majority found the IMR timelines to be directory, not mandatory, and thus the untimely IMR was valid and binding. A dissenting commissioner argued the IMR timelines are mandatory, and an untimely IMR should allow the WCAB to determine treatment necessity.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewSB 863Labor Code section 4610.6(h)Administrative Directormandatory vs. directorymedical treatment disputeprescription medicationsWellbutrin
References
27
Case No. ADJ2855195 (VNO 0550470)
Regular
Feb 06, 2014

MARCELO RUEDA vs. DRIVE SERVICE, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration of a WCJ's decision awarding $7,200 for shockwave therapy to the applicant's elbows. The Board found that the lien claimant failed to establish the medical reasonableness and necessity of the treatment, as the Agreed Medical Examiner's opinion did not specifically endorse shockwave therapy. The WCJ's exclusion of the defendant's utilization review denial letters was also questioned, but the Board reopened the record to allow for further development of evidence regarding the treatment's necessity. Consequently, the matter was returned to the trial level for further proceedings and a new decision.

Utilization Reviewshockwave therapymedical necessityAgreed Medical Examinerdeposition testimonydue processdevelopment of recordlien conferencePetition for ReconsiderationFindings and Award
References
5
Case No. ADJ6975049
Regular
Jun 05, 2018

CONSUELO VIEYRA vs. COUNTY OF LOS ANGELES

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision and returned the case for further proceedings, finding that the defendant's utilization review denials were not timely communicated to the physician. While the initial WCJ found the UR timely, the WCAB disagreed, asserting jurisdiction to determine medical necessity. Crucially, the WCAB found that the 2009 Medical Treatment Utilization Schedule (MTUS) guideline used for the denial was an invalid regulation. The matter was returned for further development of the record regarding medical necessity, considering the proper legal framework for treatment requests.

Workers' Compensation Appeals BoardConsuelo VieyraCounty of Los AngelesUtilization ReviewRequest for AuthorizationHome Health CareReasonable and Necessary TreatmentMedical TreatmentIndependent Medical ReviewMTUS Chronic Pain Medical Treatment Guidelines
References
17
Case No. ADJ693974 (OAK 0242212)
Regular
Apr 26, 2019

Glory Shreeve vs. Village Shops/ Ethan Allen Carriage House, Superior National Insurance Company, BROADSPIRE, California Insurance Guarantee Association

In this Workers' Compensation Appeals Board case, applicant Glory Shreeve sought authorization for medical treatment, which was denied by the defendant's Utilization Review (UR) provider. Applicant argued the UR denials were untimely because requests for additional information were not made by a licensed physician, thus invalidating the delays and granting the Board jurisdiction over medical necessity. The Board affirmed the Administrative Law Judge's decision, finding that the UR provider's requests for additional information did not violate Labor Code Section 4610(e) and that the denials were issued within the extended timeframes permitted by DWC Rule 9792.9.1. Consequently, the Board held it lacked jurisdiction to determine the reasonableness and necessity of the requested medical treatment due to the timely UR denials.

Utilization ReviewRequest for AuthorizationLabor Code section 4610(e)DWC Rule 9792.9.1TimelinessJurisdictionMedical NecessityCalifornia Insurance Guarantee Association (CIGA)Petition for ReconsiderationAdministrative Law Judge (WCJ)
References
2
Case No. MISSING
Regular Panel Decision
Jan 25, 1995

Claim of Weingarten v. Pathmark Stores, Inc.

The claimant sustained head, back, and right shoulder injuries in March 1989 while working for Pathmark Stores, Inc. She developed an organic mental syndrome and multiple cognitive deficits, leading to an award of permanent partial disability benefits. Later, the Workers’ Compensation Board’s Office of Vocational Rehabilitation recommended treatment at the Head Injury Technical School (HITS). Despite the employer's attempts to challenge the necessity and apportionment of the treatment costs, the Workers’ Compensation Law Judge (WCLJ) ordered the employer to pay the entire $245,000 bill, a decision affirmed by the Board. The appellate court affirmed the Board's decision, finding the employer failed to present sufficient medical evidence to contradict the necessity of the claimant's participation in the HITS program or to challenge the itemization of the bill.

brain injurycognitive deficitspermanent partial disabilityworkers' compensation benefitsmedical treatment authorizationapportionment of costsemployer liabilityadministrative appealburden of proofmedical evidence admissibility
References
8
Case No. ADJ3989406 (SDO 0252973) ADJ3350463 (SDO 0252974)
Regular

ZAYDA HERRING vs. PARADISE VALLEY HOSPITAL

The Appeals Board granted reconsideration, rescinded the prior decision, and found the defendant liable for the requested medical treatment. While the original judge denied treatment due to stale reports and unknown current need, the Board found the Agreed Medical Examiner's opinion established the reasonableness and necessity of the treatment at the time of the requests. The case is remanded to the trial level for further proceedings regarding the awarded treatment and reimbursement.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationIndependent Medical ReviewAgreed Medical ExaminerPetition for ReconsiderationJoint Findings and AwardMedical TreatmentPsychiatric InjuryPrescription Medications
References
0
Case No. MISSING
Regular Panel Decision
Oct 15, 1993

In re the Arbitration between Spinex Laboratories, Inc. & Patton

Petitioners, a diagnostic laboratory and a licensed chiropractor, appealed an order denying their application to vacate an arbitration award. They had provided testing and treatment services, including the use of a "MedX" machine, to an injured worker, Russell Shafer, for which respondent State Insurance Fund, the workers' compensation carrier, refused payment. The Chiropractic Practice Committee, to which the matter was referred by a Workers' Compensation Law Judge, disallowed the entire contested amount, finding the MedX services unnecessary. Petitioners argued the Committee exceeded its authority by determining necessity rather than just value. The Supreme Court dismissed the petition, and the appellate court affirmed, holding that "value" under the Workers' Compensation Law encompasses medical necessity and appropriateness, and the Committee's determination that the services were unnecessary had a rational basis, especially considering Shafer was no longer disabled and the nature of the treatments.

Arbitration Award VacaturWorkers' Compensation CarrierChiropractic Care ReimbursementMedical Necessity DisputeWorkers' Compensation Law InterpretationFee ReasonablenessAppellate DivisionSupreme Court OrderCPLR Article 75 ReviewMedX Machine Treatment
References
3
Case No. ADJ1718435 (MON 0341690) ADJ2131482 (MON 0340861)
Regular
May 10, 2017

JEROME MITCHELL vs. COMMUTER EXPRESS, GALLAGHER BASSETT

This case involves a lien claimant, RS Medical, seeking reconsideration after its $6,800.28 lien for medical treatment was disallowed by the WCJ. The WCJ found RS Medical failed to prove the treatment was reasonable and necessary for the admitted industrial injuries. The Appeals Board granted reconsideration, finding the WCJ erred by focusing solely on neck treatment when evidence indicated prescriptions were for multiple body parts, including admitted injuries. The matter is returned to the trial level for the WCJ to re-evaluate the medical evidence and determine the reasonableness and necessity of the treatment.

Lien ClaimReconsiderationWCJUtilization ReviewTENS deviceMedical TreatmentBurden of ProofSubstantial EvidenceReasonableness and NecessityIndustrial Injury
References
5
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