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

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. 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. ADJ7860847, ADJ7860626
Regular
May 14, 2012

FERNANDO SARMIENTO vs. PAYROLL MANAGEMENT GROUP, INC, BLUE CHIP RECYCLING, WAUSAU UNDERWRITERS INSURANCE COMPANY, LIBERTY MUTUAL

The Appeals Board vacated its prior grant of reconsideration and dismissed the defendant's petition as untimely and based on non-final orders. The Board granted removal on its own motion to consolidate two cases and affirmed the WCJs' denial of the defendant's petitions to compel the applicant to transfer care to a Medical Provider Network (MPN). While the defendant is generally not liable for treatment outside an MPN per *Valdez*, the Board found that MPN validity and notice issues, and the applicant's right to self-procure treatment at their own expense, were not yet determined. The Board clarified that the defendant can request an expedited hearing to determine entitlement to medical treatment, rather than compel MPN transfer.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPetition to CompelReconsiderationRemovalVenueConsolidationFinal OrderLabor Code
References
4
Case No. ADJ1242171 (AHM 0094407)
Regular
Sep 29, 2014

RICHARD SHAWL vs. STEVE'S AUTOMOTIVE, ARROWOOD INDEMNITY

The Workers' Compensation Appeals Board reversed a finding that the defendant properly transferred the applicant's future medical care into its Medical Provider Network (MPN). The Board found that the defendant had previously stipulated to the applicant treating with a non-MPN physician, Dr. Rabinovich, and offered no good cause to set aside that stipulation. Because the stipulation authorized treatment outside the MPN, the defendant was liable for reasonable treatment provided by Dr. Rabinovich.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNprimary treating physicianstipulationreconsiderationindustrial injuryfuture medical treatmentpermanent disabilityapportionment
References
14
Case No. ADJ9822757; ADJ9826854
Regular
Dec 07, 2016

MIREYA CASILLAS vs. CVS PHARMACY, INC., NEW HAMPSHIRE INSURANCE, GALLAGHER BASSETT SERVICES

The Appeals Board denied Mireya Casillas's Petition for Removal because she failed to demonstrate substantial prejudice or irreparable harm required for this extraordinary remedy. The WCJ's report, incorporated by the Board, found that the defendants' 24-day delay in authorizing MPN treatment did not constitute a denial of care that would permit treatment outside the MPN, especially since authorization was eventually provided before the applicant designated a non-MPN physician. The Board concluded that reconsideration would be an adequate remedy for any potential adverse decision. Therefore, removal was denied.

RemovalPetition for RemovalWorkers' Compensation Appeals BoardMedical Provider NetworkMPNDenial of CarePrimary Treating PhysicianAuthorizationPrejudiceIrreparable Harm
References
3
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. ADJ6507434
Regular
Jun 07, 2013

GABINO DANIEL MARTINEZ MONTES vs. MURRAY'S IRON WORKS, COMPWEST INSURANCE COMPANY

This case involves a lien claimant, Frontline Medical Associates, seeking reconsideration of the denial of their lien for medical treatment provided to an applicant, Gabino Daniel Martinez Montes. The lien was denied because the claimant failed to prove membership in the defendant's Medical Provider Network (MPN) or demonstrate the necessity of treatment for denied body parts. The Appeals Board adopted the WCJ's report, which found the lien claimant's evidence inadmissible due to non-disclosure and upheld the denial of reconsideration. The claimant also failed to establish that treatment for denied body parts was medically necessary or that the MPN process was properly bypassed.

Workers' Compensation Appeals BoardPetition for ReconsiderationWorkers' Compensation Administrative Law JudgeFrontline Medical AssociatesLien ClaimantMedical Provider Network (MPN)Pre-Trial Conference StatementAdmissible EvidenceDue ProcessLabor Code Section 4062
References
2
Case No. ADJ7048296
Significant
Sep 27, 2011

Elayne Valdez, Applicant vs. Warehouse Demo Services, Zurich North America, Adjusted By ESIS

The Appeals Board affirmed its prior en banc decision, holding that where unauthorized medical treatment is obtained outside a validly established and properly noticed medical provider network (MPN), the resulting non-MPN treatment reports are inadmissible and may not be relied upon to award benefits.

MPNinadmissibilitynon-MPN treatmentLabor Code section 4616.6appeals boardreconsiderationen banc decisionPTPmedical provider networkutilization review
References
17
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. ADJ7214982
Regular
Jan 06, 2012

JOAQUIN GONZALEZ vs. NFI INDUSTRIES, ZURICH AMERICAN INS. CO.

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration, upholding the WCJ's finding that the applicant received proper notice of the defendant's Medical Provider Network (MPN) and was treated within it initially. The Board also initiated sanctions against the applicant's attorney for misrepresenting witness testimony, threatening a $500 penalty unless good cause is shown otherwise. The applicant's arguments regarding non-MPN treatment non-compensability and inadmissibility of reports were rejected based on established precedent and findings of fact. The Board found the attorney's petition frivolous, demonstrating bad faith tactics.

MPNMedical Provider NetworkReconsiderationOrder of RemovalSanctionsLabor Code § 5813Bad Faith ActionsFrivolousWillful FailureImproper Motive
References
3
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