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. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
0
Case No. FRE 0222651
Regular
Jul 15, 2008

CHRISTOPHER HUNT vs. MADERA COUNTY ROAD DEPARTMENT

The Appeals Board granted reconsideration of a WCJ's decision that limited a lien claimant's facility fees to the Official Medical Fee Schedule. The Board found the WCJ erred by not applying the correct *Kunz* standard for determining the reasonableness of outpatient surgery facility fees, which considers factors beyond the fee schedule. The case is remanded for further proceedings to properly develop the record according to *Kunz*.

KunzOfficial Medical Fee Scheduleoutpatient surgery facility feeslien claimantreconsiderationen banc decisionreasonableness of feesusual feegeographical areacontractually negotiated fees
References
5
Case No. ADJ8742261
Regular
Apr 24, 2015

JOHN MURPHY vs. COUNTY OF FRESNO

The Workers' Compensation Appeals Board granted reconsideration, rescinding the prior order that awarded additional compensation to Cedars-Sinai Medical Center (CSMC). The Board determined that California Administrative Director Rule 9790, as amended, clarifies that regulations allowing payment in excess of the Official Medical Fee Schedule for extraordinary circumstances do not apply to services rendered after January 1, 2004. Therefore, CSMC is not entitled to additional payment beyond the $66,248.58 already paid, as this amount conforms to the 2004 Inpatient Official Medical Fee Schedule for services provided in 2011.

Workers' Compensation Appeals BoardCounty of FresnoCedars-Sinai Medical Center2004 Inpatient Official Medical Fee SchedulePetition for ReconsiderationAdministrative Director Rule 9790Labor Code section 5307.1Senate Bill 228extraordinary circumstanceslien claimant
References
3
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
0
Case No. MISSING
Regular Panel Decision

Doctor of Medicine in the House, P.C. v. Allstate Ins.

This case concerns a medical service provider plaintiff seeking $1,876.76 in no-fault claim benefits. The defendant insurance company denied the claim, citing that the fees were excessive under the workers’ compensation fee schedule and that prior reimbursements had exhausted the daily 8-unit limit for physical medicine procedures. The central legal question involved interpreting paragraph 11 of the Official New York Workers’ Compensation Medical Fee Schedule, Physical Medicine (2010), specifically whether the 8-unit limit applied per provider or cumulatively across all claimants. The court ruled in favor of the plaintiff, clarifying that the 8-unit rule is an individual provider fee limitation and not an exhaustion regulation for all claimants, distinguishing it from the $50,000 basic economic loss limit.

No-Fault BenefitsWorkers' Compensation Fee ScheduleMedical Reimbursement8-unit RuleFee Schedule InterpretationInsurance LawPhysical MedicineStatutory InterpretationClaim DenialExcessive Billing
References
9
Case No. ADJ3 176427 (AHM 0148942)
Regular
Feb 03, 2016

GILBERT LUNA vs. NATIONWIDE PHARMACY, LIBERTY MUTUAL

The Workers' Compensation Appeals Board affirmed a prior decision finding that Nationwide Pharmacy and Liberty Mutual's payment of $52,481.40 for spinal surgery was reasonable. Lien claimant Monrovia Memorial Hospital sought reconsideration, arguing a higher fee was warranted and they were exempt from the Official Medical Fee Schedule. However, the Board found that while the hospital was exempt from the fee schedule, it still had the burden to prove the reasonableness of its charges. The lien claimant failed to meet this evidentiary burden by a preponderance of the evidence.

Monrovia Memorial HospitalLien claimantOfficial Medical Fee ScheduleOMFS exemptionReasonable feeUsual and customary reimbursementBurden of proofFacility feesLong term care hospitalTitle 42 Code of Regulations
References
2
Case No. MISSING
Regular Panel Decision

Official Committee of Unsecured Creditors of 360networks (USA) Inc. v. Public Utilities Commission of California (In Re 360networks (USA) Inc.)

The Official Committee of Unsecured Creditors of 360networks (USA) Inc. (Debtors) initiated an adversary proceeding against the Public Utilities Commission of the State of California (CPUC) seeking to avoid certain fee payments as preferential transfers under the Bankruptcy Code. The CPUC moved to dismiss the action, asserting Eleventh Amendment sovereign immunity and arguing the court lacked jurisdiction. Judge Allan L. Gropper denied the CPUC's motion, concluding that the court holds in rem jurisdiction over the debtor's property in a preference action. The Court determined that the exercise of this jurisdiction would not offend state sovereignty, citing various forms of potential relief available, including the disallowance of claims by other California state instrumentalities.

Bankruptcy LawSovereign ImmunityEleventh AmendmentIn Rem JurisdictionPreference ActionMotion to DismissPublic Utilities CommissionCalifornia Environmental Quality ActDebtor-Creditor RelationsFederal Jurisdiction
References
45
Case No. ADJ6704917
Regular
Apr 15, 2018

Victor Diaz vs. Cor O Van, Travelers Diamond Bar

This case involves a lien claimant, Monrovia Memorial Hospital, appealing a WCJ's decision that the defendant overpaid the lien claim and that penalties and interest were moot. The lien claimant argues its charges are customary and reasonable, not subject to the Official Medical Fee Schedule, and should be reimbursed on a "reasonable cost" basis. The Appeals Board granted reconsideration to further review the lien claimant's arguments and the WCJ's findings on payment sufficiency and fee schedule applicability.

Lien claimantPetition for ReconsiderationKunzTapiaOfficial Medical Fee ScheduleLong-term acute care hospitalReasonable cost basis42 Code of Federal RegulationsGouldMedically necessary
References
3
Case No. ADJ7303882
Regular
Sep 11, 2014

ANTONIA HUERTA vs. HUENEME SCHOOL UNIFIED DISTRICT, YORK RISK SERVICES GROUP

This case concerns a hospital's claim for additional payment for an injured worker's lengthy rehabilitation stay following paraplegia after epidural injections. The hospital argued its services were exempt from the Official Medical Fee Schedule due to extraordinary circumstances and the necessity of specialized rehabilitation. The Workers' Compensation Appeals Board adopted the Administrative Law Judge's recommendation, denying the employer's petition for reconsideration. The Board found the ALJ's reasoning regarding reasonable treatment under the fee schedule and the justification for additional payment, including interest, was sound.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeReport and RecommendationStipulationsCustodianUpper ExtremitiesBackHipsLower Extremities
References
0
Case No. ADJ9725603
Regular
Nov 23, 2020

LUZ LOZA vs. GOLDBLATT GOLDBLATT/BAY AREA RESTAURANT MANAGEMENT, ARCH INSURANCE COMPANY, administered by YORK RISK SERVICES GROUP, INC.

The Workers' Compensation Appeals Board granted reconsideration of an administrative law judge's order finding the applicant entitled to pre-authorization for their treating physician to issue a PR-4 report at the medical-legal billing rate. While affirming the applicant's right to obtain the report, the Board clarified that the defendant retains the right to object to or raise defenses regarding the physician's billing. The Board reasoned that treating physicians are permitted to provide comprehensive medical-legal evaluations, and such reports are governed by specific medical-legal fee schedules, not the Official Medical Fee Schedule.

PR-4 reportmedical-legal billing ratepre-authorizationprimary treating physician (PTP)Qualified Medical Evaluator (QME)comprehensive medical evaluationOfficial Medical Fee SchedulePetition for ReconsiderationFindings of Fact and Order (F&O)Labor Code
References
3
Showing 1-10 of 4,194 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