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

Case No. ADJ156419
Regular
Feb 20, 2019

JOCELYN BOWEN vs. COUNTY OF SAN BERNARDINO

The Workers' Compensation Appeals Board reversed a prior Independent Medical Review (IMR) decision that denied the applicant's Norco prescription. The Board found the IMR reviewer failed to consider all submitted medical records and prior IMR determinations, leading to plainly erroneous findings of fact. Specifically, the IMR reviewer incorrectly stated there was no documentation of functional improvement with Norco, despite such documentation being present. The case is remanded for a new IMR review by a different reviewer or organization.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewPlainly Erroneous FindingsAdministrative DirectorLabor CodeMedical Treatment Utilization ScheduleNorcoPain ManagementOrthopedic Surgery
References
Case No. ADJ971954 (OAK 0113623)
Regular
Dec 19, 2014

LEO VIGIL vs. MILAN'S SMOKED MEATS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and affirmed the finding that the defendant's utilization review (UR) denials were untimely served, rendering them invalid. As a result, the Board found the requested medications, Norco and Pennsaid, to be reasonably necessary based on substantial medical evidence from the applicant's physician. However, the Board limited Norco refills to five, acknowledging that ongoing opioid use requires periodic review, unlike the nurse case manager services in a prior case. The case was returned to the trial level for further proceedings.

Utilization ReviewRequest for AuthorizationNorcoPennsaidTimelinessServiceInvalid URMedical NecessityDubon IDubon II
References
Case No. ADJ6933383, ADJ7271376, ADJ6776432, ADJ7016364, ADJ2548586 (VNO 0557073)
Regular
Aug 06, 2018

MELANIE SANCHEZ vs. MIANO'S FOOD CORPORATION dba IHOP, HARTFORD INSURANCE COMPANY OF THE MIDWEST, TRAVELERS CASUALY \& SURETY COMPANY

This case involves a workers' compensation applicant seeking reconsideration of a prior award. The applicant's petition for reconsideration focused solely on the denial of medical treatment, specifically Imitrex, Lipoderm, and Norco, for industrial injuries. However, the administrative law judge's previous hearing and award addressed only penalties for late payment of compensation, not the medical treatment disputes. Because the issue of medical treatment was not properly presented to or decided by the judge below, the Appeals Board denied the petition as it sought reconsideration of an issue not previously adjudicated.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Corrected Findings Award and Orderclerical errorpenaltiesattorney's feeslate paymentsmedical treatmentImitrex injectionsLipoderm patches
References
Case No. ADJ8286511
Regular
May 30, 2017

HECTOR SANCHEZ BARRAGAN vs. T&T MARKETING SERVICES, INC., STATE COMPENSATION INSURANCE FUND

This case concerns the applicant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision that upheld an Independent Medical Review (IMR) denial of a Norco prescription. The applicant argued the IMR determination exceeded the Administrative Director's authority due to a plainly erroneous application of Medical Treatment Utilization Schedule (MTUS) guidelines. The WCAB denied the petition, adopting the trial judge's report which found the IMR reviewer correctly applied medical expertise to select relevant MTUS sections for chronic opioid use. The Board determined the applicant failed to provide clear and convincing evidence of erroneous MTUS application or that the IMR decision was otherwise invalid.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardIndependent Medical ReviewUtilization ReviewNorcoMedical Treatment Utilization ScheduleAdministrative DirectorLabor CodeChronic Pain Medical Treatment Guidelines
References
Case No. ADJ3568698 (MON 0246436)
Regular
Nov 15, 2016

ROGER SCHENDEL vs. B&B SALES, STATE COMPENSATION INSURANCE FUND

In this workers' compensation case, the applicant sought renewed prescriptions for Norco and Omeprazole. Defendant contested the award of these medications, arguing the Workers' Compensation Appeals Board lacked jurisdiction due to a timely Utilization Review (UR) denial upheld by Independent Medical Review (IMR). The Board denied reconsideration, affirming the WCJ's award based on a stipulation agreement that waived the UR/IMR process in favor of an Agreed Medical Examiner (AME). The majority found defendant bound by the stipulation to abide by the AME's report, which deemed the prescriptions medically appropriate. A dissenting opinion argued the AME's report was insufficient for an award as it was not based on a current examination or complete review of the applicant's medical records.

WCABPetition for ReconsiderationFindings Award and OrdersStipulations with Requests for AwardsNorcoOmeprazoleSynvisc injectionsRequest for Authorization (RFA)Utilization Review (UR) denialIndependent Medical Review (IMR)
References
Case No. ADJ1557376 (RIV 0052354) ADJ3175359 (RIV 0053956)
Regular
Oct 20, 2008

RENEE WORLEY vs. NORCO DAISY KART FLORIST, EMPLOYERS COMPENSATION INSURANCE COMPANY

This case consolidated two workers' compensation claims for Renée Worley. The Board affirmed the original findings that she sustained no permanent disability and required no further treatment for her right hand, while awarding 14% permanent disability and further medical treatment for her bilateral upper extremities and low back for a separate injury period. The applicant's petition for reconsideration, arguing for a different disability rating schedule and additional treatment for her hand, was denied.

Workers' Compensation Appeals BoardRenee WorleyNorco Daisy Kart FloristEmployers Compensation Insurance CompanyADJ1557376RIV 0052354ADJ3175359RIV 0053956ReconsiderationFindings and Award
References
Case No. ADJ2086501 (SFO 0318776)
Regular
Nov 07, 2014

KIM McCOOL (NELSON) vs. MONTEREY BAY MEDICAR, ARROWOOD INDEMNITY COMPANY

This case involves a dispute over the authorization of pain medications for an applicant with a 1983 back injury. The employer initially denied medications based on utilization review but later approved them. The administrative law judge still awarded the medications, but the Appeals Board granted reconsideration. The Board rescinded the award, finding no actual dispute existed at the hearing and that the prior denial, though flawed, did not warrant the judge's ruling. The Board also noted concerns about the utilization review process potentially violating regulations.

Utilization ReviewPetition for ReconsiderationFindings and AwardOxyContinNorcoLyricaAmbulance DriverPermanent DisabilityExpedited HearingMedical Treatment
References
Case No. ADJ803377 (RIV 0075685) ADJ6675892
Regular
Oct 05, 2017

SANDRA ARMENTA vs. SAN BERNARDINO SHERIFF'S DEPARTMENT

The Workers' Compensation Appeals Board (WCAB) granted reconsideration to address a plainly erroneous finding of fact in an Independent Medical Review (IMR) determination. The IMR incorrectly stated there was no documentation of constipation, despite medical reports confirming this issue, which was a basis for denying Amitiza. The WCAB also noted a case numbering error in the original findings of fact. Consequently, the WCAB rescinded the findings and returned the matter to the trial level for correction and further proceedings regarding the IMR determination's validity.

WCABReconsiderationIndependent Medical Review Determination (IMR)Findings of Fact (FOF)San Bernardino Sheriff's DepartmentApplicantPlainly Erroneous FactDocumentationPain ReliefFunctional Benefit
References
Case No. ADJ3011154 (SAC 0309784) ADJ3631113 (SAC 0309785)
Regular
Aug 28, 2014

CHRISTOPHER TORRES vs. CONTRA COSTA SCHOOLS INSURANCE GROUP, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a dismissal of an applicant's Independent Medical Review (IMR) appeal, which was initially dismissed for lack of verification. While the applicant's IMR appeal did not meet the statutory requirement for verification under Labor Code section 4610.6(h), the WCAB recognized the evolving nature of this requirement and the public policy favoring disposition on the merits. The case was returned to the trial level, allowing the applicant twenty days to cure the verification defect, after which the WCJ will address the substance of the appeal or dismiss it if the defect remains uncorrected.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewVerified AppealLabor Code Section 4610.6(h)Petition for ReconsiderationRule 10450(e)Declaration of Readiness to ProceedWCJSignificant Panel Decision
References
Case No. ADJ1060696
Regular
Jan 14, 2016

MARIA URIBE RAMOS vs. PATTERSON FROZEN FOODS, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY

This case involves an applicant's appeal of Independent Medical Review (IMR) determinations regarding prescription medication refills for Flexeril and Norco. The Workers' Compensation Appeals Board (WCAB) granted the appeal for Flexeril, finding the initial IMR determination was issued in excess of the Administrative Director's powers due to an incomplete medical record. The WCAB affirmed the IMR determination for Norco, agreeing that the record was complete for that medication. A dissenting opinion argued that both IMR determinations for Flexeril and Norco, and an additional IMR determination for clonidine, were flawed and should have been remanded for further review.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.6(h)Plainly Erroneous Finding of FactIncomplete Medical RecordExcess of PowersRemandUtilization ReviewMedical Treatment Utilization ScheduleCompromise and Release
References
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