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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 The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr.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. ADJ2367528 (SFO 0509283)
Regular
Mar 22, 2011

GUILLERMO BAYLEY vs. YMCA OF THE EAST BAY, TRAVELERS INSURANCE

This case involves a dispute over the payment for a 15-day hospitalization for an industrial injury. Stanford University Medical Center, a lien claimant, sought additional payment beyond the amount calculated under the Official Medical Fee Schedule (OMFS). The Appeals Board granted reconsideration, finding that California Code of Regulations, title 8, section 9792(c) allows for fees exceeding the OMFS if extraordinary circumstances related to the unusual nature of services rendered are proven. The case was returned to the trial level for further development of evidence regarding these extraordinary circumstances and to determine if the claimed fee is reasonable.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationInpatient Hospital Fee ScheduleOfficial Medical Fee Schedule (OMFS)Extraordinary CircumstancesDiagnosis-Related Group (DRG)Reasonable FeeLabor CodeMedical Treatment
References
Case No. LAO 0832662
Regular
Mar 18, 2008

RIVALDO CASTILLO vs. BENTLEY-SIMONSON, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior award, remanding the case to the trial level. The WCJ erred by applying the Official Medical Fee Schedule to a 2003 surgery and failing to consider the *Kunz* factors for reasonableness when determining the lien claimant's facility fees. The Board will allow the WCJ to determine the reasonableness of the lien claimant's charges under *Kunz*, with the OMFS as one factor.

Wilshire SurgicenterOpinion and Order Granting ReconsiderationFindings and AwardLien ClaimantOutpatient Surgery Facility FeesOfficial Medical Fee ScheduleKunz v. Patterson Floor CoveringLabor Code section 4600Reasonableness of Facility FeeUsual Fee
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. ADJ3371067 (VNO 0458070) ADJ4100976 (VNO 0493655)
Regular
Sep 11, 2013

WILLIAM JOHNSON vs. ENVIRONMENT INDUSTRIES dba VALLEY CREST, Permissibly Self-Insured; Adjusted by ESIS

The Workers' Compensation Appeals Board amended a prior award concerning lien claims for medical treatment by two doctors. The Board allowed Dr. Kottler's medical treatment liens based on a prior agreement, but reduced payment for his medical reports to the Official Medical Fee Schedule rates. Conversely, Dr. Singh's lien for medical treatment was rescinded as he failed to meet his burden of proof to establish the reasonableness and necessity of his treatment. The majority opinion found the agreement with Dr. Kottler enforceable, while a dissenting opinion disagreed with its interpretation and favored the fee schedule amounts.

Workers Compensation Appeals BoardReconsiderationMedical Treatment LiensOfficial Medical Fee ScheduleBurden of ProofCompromise and ReleaseAgreed Medical ExaminerPsychiatric TreatmentCustomary FeeMedical-Legal Reports
References
Case No. ADJ7232076
En Banc
Sep 26, 2011

Tsegay Messele vs. Pitco Foods, Inc.; California Insurance Company

The Appeals Board holds that the 10-day period for agreeing on an AME under Labor Code § 4062.2(b) is extended by five days when the initial proposal is served by mail, and clarifies the method for calculating this time period, finding both parties' panel requests premature.

Workers' Compensation Appeals BoardTsegay MesselePitco FoodsInc.California Insurance CompanyADJ7232076Opinion and Decision After ReconsiderationOrder Granting RemovalDecision After RemovalEn Banc
References
Case No. LAO 0807776
Regular
Jan 08, 2008

Mason Dow vs. COMMERCIAL INTERIOR RESOURCES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, returning the case to the trial level for further proceedings. The Board found that the Administrative Law Judge erred by improperly applying the Official Medical Fee Schedule to a lien claimant's surgical facility fees incurred prior to its adoption. The case is remanded for the judge to determine the reasonableness of the lien claimant's charges, considering factors outlined in *Kunz v. Patterson Floor Coverings*.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFindings and AwardSurgical Facility FeesKunz v. Patterson Floor CoveringsReasonable FeeOfficial Medical Fee Schedule (OMFS)Outpatient Surgery CenterUsual Fee
References
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
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
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