CompFox Logo
AboutWorkflowFeaturesPricingCase LawInsights

Updated Daily

Case Law Database

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

Case No. ADJ3998532 (VNO 0450822) ADJ1852772 (VNO 0450819)
Regular
Jul 29, 2011

JOY A. SKEETE-PENEGAR (JOY PENEGAR) vs. BANK OF AMERICA, ARROWOOD INDEMNITY COMPANY

Lien claimants Dr. Silver and Dr. Bresler petitioned for reconsideration after the WCJ limited their fees to the Official Medical Fee Schedule (OMFS). The Appeals Board granted reconsideration, amending Dr. Bresler's award due to calculation errors from $8,235.00 to $8,157.41, and affirming Dr. Silver's award of $250.00. The Board found that the OMFS applied as the employer accepted liability for treatment and paid some services, and the lien claimants failed to prove fees exceeding the OMFS were reasonable. Penalties under Labor Code section 5814 were denied as they are not payable to lien claimants.

OMFSPetition for ReconsiderationLien ClaimantsBill Review ExpertLabor Code Section 4603.2(b)(1)PenaltiesSelf-Procured TreatmentCompensable Industrial InjuryAgreed Medical ExaminerReasonable Fee
References
Case No. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
Case No. ADJ4653538
Regular
Jun 17, 2009

DAVID ZUBIA vs. EARTHWISE TRUCKING, GALLAGHER BASSETT SCOTTSDALE

The Appeals Board granted reconsideration to amend a prior decision, but otherwise affirmed it. The employer, Earthwise Trucking, appealed a penalty and interest assessed on an unpaid medical bill, arguing they paid at the "rate in effect" and the bill was not "properly documented." The Board found that the employer's stipulation of an outstanding balance meant they did not pay the full amount due under the Official Medical Fee Schedule (OMFS) within the statutory timeframe. The Board clarified that timely payment is required according to the OMFS rate in effect on the date of service, not based on the employer's internal bill review.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardLien ClaimantPenaltyInterestOfficial Medical Fee ScheduleOMFSProperly DocumentedStipulation
References
Case No. ADJ197931
Regular
Oct 07, 2008

GENE DEL MASTRO vs. JOHN MANNINGER ELECTRIC, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board ruled that a lien claimant, Implantium, LLC, has standing to bill for surgical implants even if they are not covered by the Official Medical Fee Schedule (OMFS), as employer liability under Labor Code section 4600 is not limited to OMFS-covered services. The Board also found that Implantium's failure to file a fictitious business name statement until after providing services does not preclude reimbursement, as the statute only requires such filing to maintain an action, not for services rendered. Finally, the Board affirmed the consolidation of cases and deferred the issue of unjust enrichment for further proceedings.

Workers' Compensation Appeals BoardState Compensation Insurance FundSCIFImplantiumLLClien claimantOfficial Medical Fee ScheduleOMFSunjust enrichmentlicensing
References
Case No. ADJ4662216 (MON 0235398) ADJ1137113 (MON 0264731)
Regular
Jul 17, 2017

REBECCA WERTZ vs. HERBALIFE, AIG CLAIMS SERVICES

This case concerns Dr. Silver's lien claim for fees exceeding the Official Medical Fee Schedule (OMFS). The Appeals Board affirmed the WCJ's decision denying the lien claim, finding no statutory or regulatory basis for an "extraordinary circumstances" exception to the OMFS for services rendered after January 1, 2004. The Board also rejected due process claims regarding the exclusion of evidence and the inability to cross-examine the defendant's bill review expert. The Board concluded that lien claimant failed to prove the services were extraordinary or to demonstrate entitlement to equitable relief.

Workers' Compensation Appeals BoardLien ClaimantOfficial Medical Fee ScheduleOMFSExtraordinary CircumstancesAdministrative Director RuleSB 228Labor Code Section 5307.1Equitable ReliefDue Process
References
Case No. ADJ3496351 (SAC 0319422)
Regular
Sep 27, 2010

SANDRA L. BOYD vs. COUNTY OF SACRAMENTO

This case concerns whether lien claimant MBM Boutique Acupuncture could bill for multiple units of electro-acupuncture (CPT code 97801) per session. The defendant, County of Sacramento, argued that under the Official Medical Fee Schedule (OMFS), 97801 is an untimed code billable only once per session. The Appeals Board reversed the WCJ's decision, finding the defendant's expert bill reviewer's unrebutted testimony established 97801 as an untimed code, limiting reimbursement to one unit per session. Therefore, the defendant's payment was deemed reasonable and consistent with the OMFS, and the lien claimant was awarded nothing further.

Official Medical Fee ScheduleOMFS97801timed proceduresuntimed proceduresdeputy sheriffacupuncturereimbursementbill reviewerunit per session
References
Case No. ADJ638016 (VNO 0518817)
Regular
Mar 22, 2011

Roger Schleifstein vs. Leslie's Pool Supply, ST. PAUL'S TRAVELERS INSURANCE

This case concerns a lien claim by Grossman Medical Group for $188,310.89 in unpaid medical treatment expenses following an industrial injury. The WCAB affirmed the WCJ's decision disallowing the lien, finding Grossman Medical failed to prove its charges exceeded the Official Medical Fee Schedule (OMFS) due to extraordinary circumstances. Applicant's private health insurer, CIGNA, had already paid a significant portion of the bill, and the Appeals Board held that the statutory changes eliminating the exception for billing above OMFS in disputed claims applied. The dissenting opinion argued that Grossman Medical met its burden by demonstrating reasonable and customary fees supported by comparable cases, particularly where treatment was extensive.

Lien claimantGrossman Medical GroupOfficial Medical Fee ScheduleOMFSusual and customary feesextraordinary circumstancesreasonablenesslabor codeappeals boardcompromise and release
References
Case No. SBR 0320298
Regular
Jun 13, 2008

DANILO DeGUZMAN vs. LOMA LINDA UNIVERSITY MEDICAL CLINIC, LOMA LINDA RISK MANAGEMENT

This case concerns a dispute over the reasonable value of medical services provided by West Coast Spine Restoration Center. The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior decision, finding that the defendant properly paid the lien claimant's fees according to the Official Medical Fee Schedule. The Board determined that the lien claimant failed to meet its burden of proof to justify charges exceeding the OMFS for work hardening and functional capacity evaluations.

Workers' Compensation Appeals BoardLoma Linda University Medical CenterLoma Linda Risk ManagementDanilo DeGuzmanIndustrial InjuryRegistered NurseWork HardeningFunctional Capacity EvaluationOfficial Medical Fee ScheduleOMFS
References
Case No. ADJ8217279
Regular
May 05, 2017

PETER BOURASSA vs. DOLLAR TREE, SEDGWICK

The Appeals Board affirmed the WCJ's decision regarding applicant Peter Bourassa's workers' compensation claim. The lien claimant, Monrovia Memorial Hospital, sought payment exceeding $\$58,272.00$ for services rendered. The Board clarified that facility fees for long-term care hospitals exempt from the Official Medical Fee Schedule (OMFS) must be paid on a "reasonable cost basis." The lien claimant failed to meet its burden of proving the reasonableness of its charges under relevant case law.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien ClaimantReasonable Cost BasisOMFSKunz studyAffirmAffirmAffirm
References
Case No. ADJ6776885
Regular
Sep 02, 2016

GABRIEL SANTOS vs. PCW CONTRACTING SERVICES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's Petition for Reconsideration and denied both the lien claimant's and defendant's Petitions for Removal. The WCJ's order appointing an independent bill reviewer to assess the value of services was deemed an interlocutory procedural decision, not a final order subject to reconsideration. The WCAB found no substantial prejudice or irreparable injury to warrant removal, and clarified that while facility fees for certain long-term care hospitals are not subject to OMFS or the Administrative Director's IBR process, a WCJ can still appoint an independent bill reviewer.

WCABPetition for ReconsiderationPetition for RemovalLien ClaimantFindings and OrdersIndependent Bill ReviewerFurther Development of RecordReasonable Value of ServicesSubstantial PrejudiceInterlocutory Decision
References
Showing 1-10 of 60 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.

CompFox Logo

The AI standard for workers' compensation professionals. Faster research, deeper analysis, better outcomes.

Product

  • Platform
  • Workflow
  • Features
  • Pricing

Solutions

  • Defense Firms
  • Applicants' Attorneys
  • Insurance carriers
  • Medical Providers

Company

  • About
  • Insights
  • Case Law

Legal

  • Privacy
  • Terms
  • Trust
  • Cookies
  • Subscription

© 2026 CompFox Inc. All rights reserved.

Systems Operational