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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. SJO 0245781
En Banc

Michael A. Willette vs. AU Electric Corporation, State Compensation Insurance Fund

The Workers' Compensation Appeals Board, in an en banc decision, holds that medical treatment disputes for unrepresented employees following a utilization review must be resolved by a panel Qualified Medical Examiner (QME). The reports from the QME, treating physician, and utilization review physician are all admissible. The prior award was rescinded and the case was remanded to follow this procedure.

Workers Compensation Appeals BoardReconsiderationFindings and AwardIndustrial InjuryLow BackTailboneAlarm InstallerState Compensation Insurance FundMedical TreatmentUtilization Review
References
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
Case No. ADJ13656596
Regular
Mar 04, 2025

CARLOS CARTAGENA vs. ORION ORNAMENTAL IRON, INC.; CYPRESS INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) denied the Petition for Reconsideration filed by Cypress Insurance Company. The petition challenged a Findings and Order from November 26, 2024, which found in favor of a lien claimant, DENTAL TRAUMA CENTER. The defendant argued that the lien claimant failed to timely submit billing and that there was insufficient evidence for the dental injury. Additionally, the defendant sought retrospective utilization review. The WCAB, adopting the WCJ's report, upheld the original decision, citing that the lien claimant's billing was timely served on a co-defendant, that exceptions to the 12-month billing rule apply when a claim is initially denied as non-industrial, and that the defendant failed to present medical evidence to rebut the applicant's medical opinions. The WCAB also denied retrospective utilization review due to the defendant's initial failure to medically investigate the disputed body part.

Workers' Compensation Appeals BoardPetition for ReconsiderationLabor Code section 5909Electronic Adjudication Management SystemEAMSTransmission to Appeals BoardAD Rule 9792.9Utilization ReviewURDeferral of Utilization Review
References
Case No. ADJ2172104 (SAC 0326562)
Regular
Jan 15, 2015

THOMAS MEEKER vs. OREGON PACIFIC BUILDING PRODUCTS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT COMPENSATION INSURANCE COMPANY

This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in *Dubon II*, the Appeals Board reversed this finding. The Board ruled that under *Dubon II*, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.

Utilization ReviewRequest for AuthorizationProvigilDubon IIIndustrial InjuryPermanent DisabilityFuture Medical TreatmentPetition for ReconsiderationAdministrative Law JudgeWorkers' Compensation Appeals Board
References
Case No. RDG 0115958
Significant
Nov 16, 2004

Brice Sandhagen, Applicant vs. Cox & Cox Construction, Inc.; State Compensation Insurance Fund

The Appeals Board held that the utilization review time deadlines are mandatory; if a defendant fails to meet these deadlines, any utilization review report is inadmissible, and the defendant must use the AME/QME procedure as the objecting party.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Time DeadlinesAdmissibility of EvidenceMedical Treatment RecommendationACOEM GuidelinesAgreed Medical EvaluatorQualified Medical EvaluatorSection 4062
References
Case No. ADJ2117331 (OAK 0261803)
Regular
May 31, 2017

Janice Payne vs. Federal Express, BROADSPIRE

This case involves Janice Payne seeking reconsideration of a Workers' Compensation Appeals Board (WCAB) decision denying her weight loss program extension. The WCJ initially ruled he lacked jurisdiction due to prior Utilization Review (UR) and Independent Medical Review (IMR) denials, which were not appealed. However, the applicant argued a 2003 Compromise and Release agreement designated Dr. Mandel as the ultimate medical arbiter for treatment disputes, superseding UR/IMR. The WCAB granted reconsideration, finding the contractual agreement to use Dr. Mandel remains enforceable despite subsequent UR/IMR legislation. The case is remanded to the trial level to consider Dr. Mandel's opinions on the weight loss program's medical necessity.

Compromise and ReleaseMedical ArbiterUtilization ReviewIndependent Medical ReviewWeight Loss ProgramContractual AgreementJurisdictionSubstantial JusticeStipulationMedical Treatment Dispute
References
Case No. ADJ6765018
Regular
Nov 13, 2015

MARTIN GUERRERO vs. McKESSON CORPORATION, OLD REPUBLIC INSURANCE

The Appeals Board reversed the WCJ's decision, holding that the statutory timeframes for Independent Medical Review (IMR) determinations are directory, not mandatory. Therefore, IMR decisions issued late are still valid and binding on the applicant. The Board concluded that the Legislature's intent was for IMR to be the sole avenue for resolving medical treatment disputes post-utilization review, ensuring consistent application of evidence-based standards. The case was returned to the trial level for further proceedings consistent with this decision.

Independent Medical ReviewIMRAdministrative DirectorLabor Code Section 4610.6Directory vs. Mandatory TimeframesMedical Treatment DisputesUtilization ReviewMedical NecessityWorkers' Compensation Appeals BoardSB 863
References
Case No. ADJ9767710
Regular
Jun 21, 2016

BRENT BAISCH vs. VIDEO ONLY, INC., LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied defendant's petition for reconsideration of an award for continued care at CareMeridian. The Administrative Law Judge found the defendant failed to conduct timely utilization review (UR) for the applicant's continued care, rendering the UR invalid. The Board agreed that the untimely UR allowed them to determine the medical treatment dispute and that continued care at CareMeridian was reasonable and necessary pending an appropriately arranged transfer. The Board affirmed the finding that the defendant failed to comply with statutory requirements for concurrent UR.

Workers Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewLabor Code Section 4610Concurrent ReviewRequest for AuthorizationFindings and AwardPetition for ReconsiderationIndustrial InjuryMedical Treatment Dispute
References
Case No. ADJ3135829 (AHM 0099139)
Regular
Jul 28, 2014

CAROLYN BERTRAND vs. COUNTY OF ORANGE, YORK

This case concerns a dispute over medical treatment disputes between an applicant and the County of Orange. The parties had previously stipulated to have the Agreed Medical Examiner (AME), Dr. Wilson, resolve future treatment disputes, potentially bypassing the statutory Utilization Review (UR) and Independent Medical Review (IMR) processes. The Workers' Compensation Appeals Board (WCAB) dismissed the employer's petition for reconsideration as the prior order was procedural, but granted removal. As a decision after removal, the WCAB clarified that while the stipulation to use the AME is valid and can supersede IMR, treatment requests must first go through UR, and only subsequent disputes are referred to the AME.

StipulationAgreed Medical ExaminerAMEUtilization ReviewURIndependent Medical ReviewIMRRemovalPetition for ReconsiderationLabor Code section 4610
References
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