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

Case No. ADJ3685938 (WCK 0066506)
Regular
Dec 02, 2014

EMMETT BOONE vs. DREYER'S GRAND ICE CREAM, FIREMAN'S FUND INSURANCE COMPANY

In this workers' compensation case, the Appeals Board affirmed a prior award finding defendant's utilization review (UR) denials for prescription refills invalid. The Board agreed with the WCJ that the UR denials were untimely because the defendant failed to communicate the decisions to the treating physician within the statutory 24-hour timeframe. Consequently, the Board found the UR invalid, allowing the WCAB to determine medical necessity based on substantial evidence. This decision upholds the applicant's right to ongoing prescription refills.

Workers' Compensation Appeals BoardUtilization ReviewReconsiderationFindings and AwardPrescription RefillsMedical TreatmentDefective DenialTimeliness RequirementsLabor Code § 4610Dubon v. World Restoration
References
8
Case No. MISSING
Regular Panel Decision

People v. Baghai-Kermani

This case concerns an appeal from two Supreme Court orders regarding a defendant's conviction for criminal sale of prescription for a controlled substance. The trial court initially granted the defendant's CPL 440.10 motion to set aside his conviction due to Rosario material violations, but denied his motion on jurisdictional grounds. On appeal, the higher court modified the Rosario order, reinstating most of the convictions, arguing that the Rosario violation for two counts did not necessarily taint the entire indictment. The court affirmed the denial of the jurisdictional motion, holding that the Attorney-General had broad jurisdiction under Executive Law § 63 (3) to prosecute the defendant for offenses connected with Medicaid, despite the defendant no longer being a Medicaid provider.

Criminal Sale of Controlled SubstanceCPL 440.10Rosario MaterialBrady v MarylandJurisdictionExecutive Law § 63 (3)Medicaid FraudAppellate ReviewBench TrialSelf-representation
References
6
Case No. ADJ1060696
Regular
Jan 14, 2016

MARIA URIBE RAMOS vs. PATTERSON FROZEN FOODS, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY

This case involves an applicant's appeal of Independent Medical Review (IMR) determinations regarding prescription medication refills for Flexeril and Norco. The Workers' Compensation Appeals Board (WCAB) granted the appeal for Flexeril, finding the initial IMR determination was issued in excess of the Administrative Director's powers due to an incomplete medical record. The WCAB affirmed the IMR determination for Norco, agreeing that the record was complete for that medication. A dissenting opinion argued that both IMR determinations for Flexeril and Norco, and an additional IMR determination for clonidine, were flawed and should have been remanded for further review.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.6(h)Plainly Erroneous Finding of FactIncomplete Medical RecordExcess of PowersRemandUtilization ReviewMedical Treatment Utilization ScheduleCompromise and Release
References
3
Case No. ADJ1122368 (SJO 0223390)
Regular
Mar 24, 2015

MINH LY vs. LORAL SPACE SYSTEMS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE NATIONAL INDEMNITY COMPANY, in liquidation

The Appeals Board granted removal and rescinded the WCJ's order taking the case off calendar, holding that the applicant is entitled to an expedited hearing regarding the denial of Lyrica prescription refills. The WCJ erred by prematurely determining that utilization review (UR) was timely and jurisdictionally barred further proceedings, without allowing evidence and a hearing. The Board emphasized that the applicant has a right to an expedited hearing to contest UR decisions, challenge their applicability, or present evidence of changed circumstances. The case was returned to the trial level for an expedited hearing and a new decision based on the record.

Utilization ReviewIndependent Medical ReviewPetition for RemovalExpedited HearingOrder Taking Case Off CalendarPrescription MedicationLyricaDue ProcessLabor Code Section 5310Dubon II
References
10
Case No. ADJ2296444 (LAO 0786271)
Regular
Feb 10, 2015

CAROLYN HOLMAN vs. LOS ANGELES UNIFIED SCHOOL DISTRICT, P S-I, A B SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board affirmed a WCJ's decision denying liens for Dr. Burstein and The Prescription Center. The Board found no evidence Dr. Burstein treated the applicant for industrial injuries, nor that his services or charges were reasonable and necessary. Consequently, The Prescription Center's lien for filling prescriptions from Dr. Burstein was also denied as not related to the industrial injury. Both lien claimants failed to meet their burden of proof regarding the reasonableness and necessity of their claims.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings and OrdersWCJStipulations with Request for AwardIndustrial injuryReasonableness of chargesNecessity of servicesBurden of proof
References
2
Case No. ADJ2263476 (VNO 0318779)
Regular
Apr 20, 2016

DARLENE FERRONA vs. WARNER BROTHERS, TIME WARNER ENTERTAINMENT CO; ZURICH LOS ANGELES

This case concerns Darlene Ferrona's entitlement to 24/7 home health care following a psyche and fibromyalgia injury. The defendant, Warner Brothers, sought reconsideration of an order granting these services, arguing that utilization review only authorized limited care and that new prescriptions were required per Labor Code section 4600(h). The Appeals Board denied reconsideration, affirming that the applicant's prior authorization of 24/7 home health care by treating physicians and subsequent stipulation established ongoing need. The Board clarified that while a prescription date is crucial for liability, a new prescription is not always necessary to continue approved, ongoing home health care if the applicant's condition has not changed, citing the precedent of *Patterson v. The Oaks Farm*.

Workers' Compensation Appeals BoardDarlene FerronaWarner BrothersZurich Los Angelesindustrial injurypsychefibromyalgiahome health careutilization reviewsubstantial medical evidence
References
5
Case No. ADJ7935139
Regular
Jul 23, 2013

SERGIO SANCHEZ MURILLO vs. PIZZA-PASTA KITCHEN, INC.

The Workers' Compensation Appeals Board dismissed the applicant's petition for removal. This dismissal was based on the administrative law judge's (WCJ) denial of the applicant's initial petition to join the Uninsured Employers Benefits Trust Fund, finding insufficient evidence. However, the applicant subsequently refiled the petition with exhibits attached to the removal petition. The WCJ will now review this refiled petition and its exhibits on remand to act appropriately.

Petition for RemovalUninsured Employers Benefits Trust FundUEBTFWorkers' Compensation Administrative Law JudgeWCJEAMSReport and Recommendationdismissalapplicantdefendants
References
0
Case No. ADJ2215482
Regular
Oct 14, 2008

NANCY MCLEARY vs. SATURN OF THOUSAND OAKS, DCH MANAGEMENT, ZURICH NORTH AMERICA

This case concerns an applicant seeking workers' compensation for an industrial injury to her back and neck, which exacerbated her need for refills of an intrathecal opiate pump. The defendant argued the pump refills were not industrial in origin, but the Board affirmed the original award, applying the principle that if an industrial injury contributes to the need for medical treatment, the employer is responsible for the entire cost. The Board granted reconsideration solely to defer the issue of the applicant's attorney's fees pending a Supreme Court decision on a related matter.

intrathecal pumpopiate solution refillsindustrial injurypreexisting conditionmedical treatment apportionmentcure or relieveagreed medical evaluatorpain management specialistprior motor vehicle accidentapplicant testimony
References
5
Case No. ADJ7488842
Regular
Jan 09, 2013

MARLENE HERNANDEZ vs. SERGIO'S TACOS, THE HARTFORD

This case involves a lien claimant, Dr. Issac Regev, who mistakenly refiled a settled workers' compensation lien. The Workers' Compensation Appeals Board granted reconsideration of the initial dismissal and sanctions, acknowledging the refiling was due to a clerical error. While affirming the dismissal of the lien, the Board reduced the sanctions from $2,500 to $500, finding it a more appropriate penalty for the error and the resulting wasted effort. The decision emphasizes the need for improved filing processes to prevent future superfluous filings.

Workers Compensation Appeals BoardReconsiderationDismissing LienSanctionsFrivolous LienClerical ErrorCompromise and ReleaseCumulative TraumaBad Faith ActionsLabor Code Section 5813
References
0
Case No. ADJ7763946
Regular
May 06, 2013

CLIFFORD MULFORD vs. EL TORO RV, INC.; THE HARTFORD, Administered By AMERICAN ALL-RISK LOSS ADMINISTRATION

The applicant sustained a catastrophic brain injury after falling from a ladder while employed. The Workers' Compensation Appeals Board denied reconsideration and dismissed removal, upholding the WCJ's finding that the employer was not liable for home health care from October 23, 2012, onward. This decision was based on the retroactive application of Labor Code section 4600(h), which requires a physician's prescription for home health care. The Board found that the applicant's physician's reports did not contain a sufficient prescription to trigger employer liability under the new statute.

Workers Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalFindings & Orderindustrial injurycatastrophic brain injuryhome health careLabor Code § 4600(h)physician's prescriptionprospective application
References
4
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