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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. SAC 286368
Regular
Jan 25, 2008

DALE OLIVER vs. BRIAN WILLIAMS CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking approval for disc replacement surgery for a work-related back injury. The defendant argued the surgery is experimental per ACOEM guidelines, thus not covered. The Board denied reconsideration, finding the applicant's physician rebutted the presumption of experimental status. The Board determined the surgery is no longer experimental, citing FDA approval, and is reasonably required for the applicant's specific condition, supported by expert medical opinion.

Workers' Compensation Appeals BoardBrian Williams ConstructionState Compensation Insurance Fundindustrial injuryright anklefootelbowshoulderskneesleft lower extremity
References
Case No. ADJ12728611
Regular
Apr 09, 2020

MARTIN JACOBO vs. COKE FARM, RISICO CLAIMS MANAGEMENT

The Workers' Compensation Appeals Board granted the defendant's Petition for Removal because the WCJ exceeded their authority by invalidating a Qualified Medical Examiner (QME) solely based on the specialty of occupational medicine for a post-surgical knee evaluation. The Board determined that an occupational medicine physician is appropriately qualified to assess such injuries according to DWC guidelines. Therefore, the WCJ's decision was rescinded, and the case was returned for further proceedings, suspending action on the Compromise and Release agreement pending further development.

Petition for RemovalPanel Qualified Medical ExaminerPQMEOccupational MedicineToxicologyPost-surgical kneeLabor Code section 4062.2(b)Administrative Director Rule 35.5Scope of practiceClinical competence
References
Case No. ADJ9074552; ADJ9074553
Regular
Jul 01, 2014

VINCENT HERNANDEZ vs. COUNTY OF MONTEREY, INTERCARE HOLDINGS INSURANCE SERVICES, INC.

The Workers' Compensation Appeals Board dismissed the applicant's Petition for Removal regarding the selection of an Occupational Medicine QME panel. The Board adopted the WCJ's report, which found that the defendant's request for an Occupational Medicine QME panel complied with Labor Code Section 4062.2. The report reasoned that Title 8 California Code of Regulations Section 31.1(b)'s requirement for supporting documentation for specialty changes does not invalidate a request if not provided. Additionally, the Board found the applicant's arguments regarding an unfair advantage and the WCJ's interpretation of Section 31.1 to be misplaced.

Workers' Compensation Appeals BoardPetition for RemovalWCJQME panelOccupational MedicineTitle 8 California Code of Regulations Section 31.1Labor Code Section 4062.2Treating PhysicianPhysical Medicine and RehabilitationMedical Unit
References
Case No. LBO 0369190
Regular
Apr 21, 2008

MARTIN PEREZ vs. ROYAL CABINETS, EMPLOYERS DIRECT INSURANCE CO.

This case concerns a lien claim by a chiropractor for $13,474.90 for 45 visits. The Workers' Compensation Appeals Board (WCAB) reconsidered the decision, determining that Labor Code Section 4604.5(d)(1) limits chiropractic visits to 24 per industrial injury for injuries after January 1, 2004. The WCAB found the lien claimant failed to prove the existence of a second cumulative trauma injury, therefore limiting the lien to 24 visits.

Workers' Compensation Appeals BoardPetition for ReconsiderationCompromise and ReleaseLien ClaimantChiropractic TreatmentLabor Code Section 4604.5(d)(1)Medical Treatment Utilization ScheduleAmerican College of Occupational and Environmental MedicineOccupational Medicine Practice GuidelinesCumulative Trauma Injury
References
Case No. ADJ6989761
Regular
Sep 30, 2013

ELVIN SALGUERO vs. CHARLES GEMEINER CABINETS, INSURANCE COMPANY OF THE WEST

This case involves an applicant seeking reconsideration of a denial for 24/7 home care. The applicant argues the denial was an abuse of discretion, as medical evidence supported the need for such care due to suicidal ideation and depression. The Workers' Compensation Appeals Board denied the petition, adopting the judge's report which found no support for 24/7 home care in relevant treatment guidelines. The judge concluded that the applicant failed to prove the requested care was reasonable and necessary beyond the requirements of existing guidelines.

WCABPetition for ReconsiderationHand Surgery EvaluationStellate Block ProceduresHome CarePsychiatric TechnicianLicensed Vocational NurseSuicidal IdeationPsychiatric HospitalizationLabor Code Section 4600(b)
References
Case No. LAO 0864684
Regular
Nov 23, 2008

VICTORIA VEGA vs. ARAMARK, ACE, USA

The Workers' Compensation Appeals Board granted reconsideration and returned the case to the trial level for further proceedings. The Board found that the Medical Provider Network (MPN) notice issue was timely raised and requires further determination by the WCJ. Additionally, the WCJ must address the limits on chiropractic visits under Labor Code section 4604.5(d)(1) and other potential violations.

Medicallegal reportMedical Provider Network (MPN)Knight v. United Parcel ServiceLabor Code section 4616.3(b)Gee v. Workers' Comp. Appeals Bd.Labor Code section 4062.9Labor Code section 139.3Compromise and Release (C&R)Occupational Medicine Practice GuidelinesLabor Code section 4604.5(d)(1)
References
Case No. ADJ9348004
Regular
May 26, 2015

DOLORES NATIVIDAD vs. SHERBOURNE PROPERTIES, INC., EMPLOYERS COMPENSATION INSURANCE COMPANY

The defendant petitioned for removal, challenging the WCJ's decision to validate a chiropractic QME panel. The applicant failed to follow the rule requiring justification for requesting a specialty other than the treating physician's. However, the defendant's objection to the QME panel was deemed untimely as it was not raised with the Medical Unit promptly. The Appeals Board denied the petition for removal, finding the defendant failed to demonstrate prejudice or irreparable harm.

Petition for RemovalAmended Findings of Fact and OrderQualified Medical Evaluator (QME) panelAdministrative Director Rule 31.1(b)Labor Code section 4060occupational medicinechiropractic medicineorthopedic medicineMedical UnitDeclaration of Readiness to Proceed
References
Case No. ADJ1798944 (LBO 0326931)
Regular
Jun 13, 2018

MARIA FIGUEROA vs. HELP NET, INC., STATE COMPENSATION INSURANCE FUND

This case concerns a lien claimant's petition for reconsideration of a WCJ's decision disallowing his lien for chiropractic services provided between 2001 and 2005. The Appeals Board rescinded the WCJ's decision, finding the claimant's petition timely due to defective service. Crucially, the Board determined that the Medical Treatment Utilization Schedule (MTUS) was improperly applied; instead, the American College of Occupational and Environmental Medicine (ACOEM) guidelines, in effect during the treatment period, should govern the determination of reasonable and necessary care. The matter is remanded to the WCJ for further proceedings consistent with the ACOEM guidelines.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and OrderMedical Treatment Utilization Schedule (MTUS)American College of Occupational and Environmental Medicine (ACOEM)Labor Code Section 4600(b)SB 899Compromise and ReleaseAgreed Medical Examiner (AME)
References
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