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

Case No. ADJ7684442, ADJ7684554
Regular
Dec 11, 2014

JAMIE VARGAS vs. SELIGMAN WESTERN ENTERPRISES, LTD, CYPRESS INSURANCE

The Workers' Compensation Appeals Board (WCAB) denied the applicant's petition for reconsideration and dismissed their petition for removal. The WCAB affirmed the administrative law judge's finding that the defendant's utilization review (UR) determinations denying authorization for opioid medication were valid because they were timely made. As the UR decisions were timely, the applicant's challenge to the denial of medication authorization is limited to the Independent Medical Review (IMR) process, not the WCAB's jurisdiction for medical necessity. The Board distinguished this case from *Patterson* by noting that ongoing opioid medication use is subject to periodic review, unlike the nurse case manager services at issue in *Patterson*.

Workers' Compensation Appeals BoardUtilization ReviewReconsiderationRemovalHydrocodoneChronic PainMedical Treatment GuidelinesIndependent Medical ReviewLabor Code §4610.5Dubon II
References
11
Case No. 529286
Regular Panel Decision
Mar 16, 2020

Matter of Forte v. Muccini

Claimant Chris Forte, who suffered a back injury and developed opioid dependence, appealed a Workers' Compensation Board decision. The Board modified a WCLJ's ruling, directing Forte to be weaned from narcotic medications based on an independent medical examiner's report and the Board's Non-Acute Pain Medical Treatment Guidelines, which limit opioid dosage to 100 mg MED, whereas Forte was taking nearly 2,500 mg MED. The Appellate Division affirmed the Board's decision, finding substantial evidence to support crediting the IME's opinion over that of the claimant's treating physician, and upheld the Board's authority to resolve conflicting medical opinions.

Opioid WeaningChronic PainWorkers' Compensation BoardMedical Treatment GuidelinesIndependent Medical ExaminationPermanent Partial DisabilityNarcotic PrescriptionArachnoiditisPharmacological Chart ReviewOpioid Dependence
References
5
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
6
Case No. 2020 NY Slip Op 07648 [189 AD3d 1870]
Regular Panel Decision
Dec 17, 2020

Matter of Connors v. Yonkers Contr. Co.

William Connors, the claimant, suffered work-related injuries in 2006. In 2017, his employer and its carrier, Yonkers Contracting Company, requested the WCLJ to direct Connors to be weaned from opioid medications, but this was denied. The carrier appealed to the Workers' Compensation Board, but their application was denied for being filed on an outdated RB-89 form, violating 12 NYCRR 300.13 (b) (1). The Appellate Division, Third Department, affirmed the Board's decision, concluding that the Board did not abuse its discretion by denying the application due to the carrier's non-compliance with the prescribed formatting requirements for Board review.

Workers' CompensationOpioid WeaningAdministrative ReviewRB-89 FormProcedural ComplianceBoard Review ApplicationForm RequirementsAppellate ReviewThird DepartmentWCLJ Decision
References
6
Case No. ADJ4092389 (SBR 0291114), ADJ4203796 (SBR 0291115), ADJ3646941 (SBR 0309645)
Regular
Jul 20, 2018

Gregory Long vs. RALPHS GROCERY COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board (WCAB) denied reconsideration of a Findings and Order that found the defendant complied with a prior Independent Medical Review (IMR) decision. The WCAB affirmed the administrative law judge's ruling that each prescription for applicant Gregory Long's opioid pain medication requires separate Utilization Review (UR) and potential IMR, despite a previous IMR approval. The Board also noted its lack of jurisdiction to hear constitutional challenges to the UR/IMR process. Applicant's claims of unequal protection and fraud were rejected, and the WCAB found no impairment to his access to medical treatment.

Workers' Compensation Appeals BoardGregory LongRalphs Grocery CompanySedgwick Claims Management ServicesPetition for ReconsiderationFindings and OrderExpedited HearingWCJIMR determinationUtilization Review (UR)
References
5
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
1
Case No. ADJ896085
Regular
Nov 07, 2014

VALERIO FLORES vs. HVOLVOLL-JOHNSON CONSTRUCTION, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY COMPANY

This case involves a workers' compensation applicant seeking authorization for analgesic medications. The applicant's physician submitted requests, which the employer's utilization reviews (URs) denied as untimely. The Administrative Law Judge found the URs untimely and ordered authorization, disallowing the employer's UR denial documents as evidence. The employer sought reconsideration, arguing the Appeals Board lacked authority over UR timeliness and medical necessity. The Board affirmed the ALJ's decision, citing precedent that the Board retains authority over untimely URs and can determine medical necessity based on evidence when URs are invalid. The employer waived their right to challenge the timeliness finding or the medical evidence by not raising these points in their petition.

Workers' Compensation Appeals BoardUtilization ReviewRequest For AuthorizationUntimelyIndependent Medical ReviewMedical NecessityFindings And AwardPetition For ReconsiderationEn Banc DecisionDubon v. World Restoration
References
4
Case No. 2020 NY Slip Op 03966 [185 AD3d 1263]
Regular Panel Decision
Jul 16, 2020

Matter of McKay v. Southampton Hosp.

The case concerns an appeal by Jacqueline McKay (claimant) from a Workers' Compensation Board decision. The Board had affirmed a Workers' Compensation Law Judge (WCLJ) ruling to consider weaning the claimant from opioid medications based on an independent medical examiner's opinion under the Non-Acute Medical Treatment Guidelines (NAPMTG). The claimant argued that the Board exceeded its authority in promulgating these guidelines. The Appellate Division, Third Department, affirmed the Board's decision, holding that the Board properly exercised its broad regulatory power under the Workers' Compensation Law to issue the NAPMTG. The court found the guidelines rational and not unreasonable, arbitrary, capricious, or contrary to the statute, emphasizing that the NAPMTG furthered the aim of ensuring prompt and appropriate medical care for injured workers by expanding existing treatment guidelines to address comprehensive pain management, including the safe use of narcotics.

Medical Treatment GuidelinesOpioid WeaningRegulatory AuthorityAdministrative LawAppellate ReviewPain ManagementOccupational DiseasePermanent Partial DisabilityWorkers' Compensation BoardIndependent Medical Examination
References
5
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