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

Case No. ADJ3664982
Regular
May 13, 2009

CYNTHIA SALGADO vs. COUNTY OF ORANGE, SOUTHERN CALIFORNIA RISK MANAGEMENT ASSOCIATION

This case concerns whether medical reports from a physician outside the defendant's Medical Provider Network (MPN) were admissible and if the applicant should repay temporary disability benefits. The Appeals Board granted reconsideration, reversing the WCJ's exclusion of the non-MPN physician's reports and reinstating temporary disability benefits. The Board found the WCJ improperly rescinded prior rulings, and restitution was unwarranted as the applicant did not act fraudulently. The matter was remanded to determine the defendant's credit for payments made to the non-MPN physician.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNAdmissibility of Medical ReportsReconsiderationRestitutionTemporary Disability IndemnitySelf-Procured Medical TreatmentLabor Code Section 4605Res Judicata
References
9
Case No. 01-14-00767-CV
Regular Panel Decision

Shirley Lenoir, Individually and as Personal Representative of the Estate of Shana Lenoir and Christopher McKnight , Individually and as Next Friend of Nayla McKnight v. U.T. Physicians

This is a health care liability appeal where Shirley Lenoir and Christopher McKnight, individually and as representatives of the Estate of Shana Lenoir and Nayla McKnight, challenge the trial court's decision to grant U.T. Physicians' plea to the jurisdiction and motion to dismiss. The appellants allege that U.T. Physicians' negligence in treating Shana Lenoir’s twin pregnancy, specifically the administration of a medically unnecessary and contraindicated progesterone injection by Nurse Matthews, proximately caused her death. U.T. Physicians claimed sovereign immunity as a governmental unit. Appellants argue that U.T. Physicians is a private non-profit corporation and an independent contractor, not entitled to sovereign immunity, and that a waiver of immunity under the Texas Tort Claims Act was sufficiently pled due to the use of tangible physical property.

Sovereign ImmunityGovernmental UnitIndependent ContractorTexas Tort Claims ActHealth Care LiabilityMedical MalpracticeNegligenceProgesterone InjectionTwin PregnancyWrongful Death
References
16
Case No. ADJ11059073
Regular
Jan 17, 2023

SHERRILL CLAYTOR vs. ALEXANDER R. LATTERI, M.D., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision allowing the applicant to treat with Dr. Spencer outside the defendant's Medical Provider Network (MPN). The WCAB found insufficient evidence that Dr. Spencer, or the applicant's previously selected physician Dr. Small, were definitively part of the defendant's MPN at the time of the request. Therefore, without proper MPN notification and an established denial of care, the applicant retained the right to resume treatment with her non-MPN physician, Dr. Spencer. The defendant may still attempt to transfer the applicant's care into the MPN by following proper statutory procedures.

MPNPTPmedical provider networkprimary treating physicianreconsiderationfindings and ordertransfer of caredenial of caresubstantial evidenceadministrative director rules
References
10
Case No. ADJ3002639 (LAO 0881928)
Regular
Jun 11, 2012

MIGUEL NAVA vs. BARRETT BUSINESS SERVICES, INC.

This case concerns an applicant's industrial injury to his spine and knees. The defendant sought reconsideration of a decision that allowed reimbursement for non-MPN providers before November 28, 2008. The Appeals Board granted reconsideration, finding the applicant was bound to select an MPN physician as of his March 11, 2008 deposition stipulation. Therefore, non-MPN services rendered after March 11, 2008, are not compensable.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNBarrett Business ServicesCorVel MPNLien ClaimantIndustrial InjurySpine InjuryKnee InjuryReconsideration
References
2
Case No. ADJ7897857
Regular
Feb 29, 2012

ALFONSO PONCE DE LEON vs. BARRETT BUSINESS SERVICES, CORVEL INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a trial judge's order allowing applicant treatment outside the defendant's Medical Provider Network (MPN). The WCAB found the judge improperly investigated the facts himself, violating judicial ethics. The evidence gathered by the judge did not definitively prove MPN non-compliance, and the judge failed to contact all listed physicians. Therefore, the case was returned for a new hearing where parties must present their own evidence regarding MPN physician availability.

MPNMedical Provider NetworkWorkers' Compensation Appeals BoardWCJReconsiderationAccess StandardsRegular PhysicianIndustrial InjuryOrthopedic SpecialistExpedited Hearing
References
0
Case No. ADJ8205235
Regular
Feb 06, 2013

HECTOR GOMEZ vs. FASTENAL, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

This case concerns an injured worker, Hector Gomez, who sought medical treatment outside his employer's Medical Provider Network (MPN). The Board overturned the finding that the employer lost control of medical treatment, finding that the employer's technical failure to schedule the initial MPN visit did not deny treatment. The Board also held that the worker could not select a non-MPN specialist simply because an MPN specialist declined to act as a primary treating physician. Therefore, the applicant must obtain treatment through the defendant's MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)SpecialistLabor Code section 4616.3Administrative Director's Rule 9767.6initial medical evaluationchange of physicianforfeiture of medical controlaccess standards
References
1
Case No. ADJ324819 (SAL 0120615) ADJ3483975 (SAL 0119560)
Regular
Jul 20, 2010

KATHERINE GONZALES vs. COUNTY OF MONTEREY, LIBERTY MUTUAL

This case concerns an injured worker's attempt to continue treatment with her physician, Dr. Klassen, after he left the defendant's Medical Provider Network (MPN). The defendant argued that the worker's condition did not meet the criteria for continued treatment with a non-MPN physician under Labor Code section 4616.2. The Workers' Compensation Appeals Board (WCAB) granted reconsideration because there was insufficient medical evidence to determine if the worker's condition qualified. The WCAB rescinded the prior decision and returned the case for further proceedings, ordering the trial judge to obtain a report from Dr. Klassen regarding the necessity of continued treatment.

Workers' Compensation Appeals BoardMPNMedical Provider NetworkLabor Code section 4616.2continuity of treatmentprimary treating physicianacute conditionserious chronic conditionterminal illnessauthorization
References
0
Case No. ADJ7781676
Regular
Nov 01, 2017

TERESA HERNANDEZ vs. T K & J, INC., dba LAS PALMAS RESTAURANT, PREFERRED EMPLOYERS INSURANCE COMPANY

This case involves a lien claim by Comprehensive Outpatient Surgery Center for medical treatment provided to applicant Teresa Hernandez. The applicant sustained a complex injury in 2010, and the employer provided some treatment through Dr. Lane, an MPN physician, including surgeries. The lien claimant contended that proper MPN notice was not provided and that the applicant was therefore entitled to seek treatment outside the MPN. However, the Appeals Board denied reconsideration, finding that the lien claimant failed to demonstrate that any lack of notice resulted in a denial of reasonable medical treatment, a burden of proof established by statute. Therefore, the employer was not liable for the applicant's self-procured treatment with non-MPN providers.

MPNLien ClaimantPetition for ReconsiderationFindings and OrderMedical Provider NetworkReasonably Necessary Medical TreatmentSelf-ProcureBurden of ProofLabor CodeSB 863
References
4
Case No. ADJ7422993
Regular
Apr 06, 2015

SHIRLEY LESCALLETT vs. WAL-MART, ACE AMERICAN INSURANCE, YORK RISK SERVICES

In this workers' compensation case, the applicant sought to select a pain management specialist as her primary treating physician. The employer's Medical Provider Network (MPN) did not have any pain management specialists within the 15-mile/30-minute access standard for primary physicians, though it did have specialists within a 30-mile/60-minute radius. The Appeals Board affirmed the WCJ's decision, holding that if an applicant chooses a specialist for their primary care, the MPN must provide at least three physicians of that specialty within a 15-mile/30-minute radius. Since the defendant's MPN failed to meet this standard for pain management specialists, the applicant was permitted to choose one outside the MPN. A dissenting opinion argued that the 30-mile/60-minute standard for specialists should apply, allowing the applicant to select a physician within that broader radius from the MPN.

MPNMedical Provider NetworkPrimary Treating PhysicianSpecialistAccess StandardsAdministrative Director's RulePain Management PhysicianGeographic RadiusLabor CodeWorkers' Compensation Appeals Board
References
3
Case No. ADJ916063 (VNO 0541860)
Regular
Mar 10, 2011

TERRY SCUDDER vs. VERIZON CALIFORNIA, INC.; Permissibly Self-Insured, Administered by SEDGWICK CMS

This case concerns an applicant who sustained industrial injuries and pre-designated a physician outside of the employer's established Medical Provider Network (MPN). The applicant's attorney subsequently referred him to physicians outside the MPN, whose reports were admitted by the WCJ. The Appeals Board overturned this, ruling that only the pre-designated physician, or referrals from that physician, could be outside the MPN and that referrals by an attorney were invalid. Consequently, the reports of these outside physicians were inadmissible, and the issues decided based on them were returned for further proceedings.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPre-designationTreating PhysicianQualified Medical EvaluatorQMEPermanent and Stationary DateApportionmentSelf-Procured Medical Treatment
References
1
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