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

Case No. ADJ9884089
Regular
Feb 03, 2017

Ray Bonilla vs. San Diego Personnel and Employment DBA Good People Employment Services, Zurich American Insurance Company

This case involves a dispute over whether a Medical Provider Network (MPN) physician's recommended treatment requires Utilization Review (UR) before authorization. The Appeals Board rescinded the prior award, holding that MPN second opinion physician recommendations are not exempt from UR. The Board clarified that while MPN dispute resolution exists, it does not preclude the insurer's right to UR. However, the matter was returned for further proceedings to determine if a proper Request for Authorization (RFA) was submitted, as an improperly submitted RFA would relieve the insurer of its UR obligation.

Workers' Compensation Appeals BoardMedical Provider NetworkUtilization ReviewRequest for AuthorizationMPN Second OpinionDWC Form RFAMedical Treatment Utilization ScheduleAdministrative Director's RuleLabor Code Section 4610Independent Medical Review
References
Case No. ADJ9712319
Regular
Jun 20, 2025

ELEANOR DIAZ NEVAREZ vs. ELK GROVE UNIFIED SCHOOL DISTRICT, SCHOOLS INSURANCE AUTHORITY

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by defendant Elk Grove Unified School District. The Board affirmed the WCJ's decision that the utilization review (UR) was untimely and procedurally defective, specifically regarding a Request for Authorization (RFA) for an H-Wave device. The defendant had argued the RFA was incomplete, but the Board found it procedurally complete, thus triggering UR obligations. The Board concluded that the defendant's failure to issue a timely conditional denial, as required by regulations, rendered the UR invalid and untimely. Additionally, the Board confirmed its decision was issued in compliance with the 60-day timeframe stipulated by Labor Code section 5909.

WCABPetition for ReconsiderationLabor Code section 5909TransmissionElectronic Adjudication Management SystemEAMSReport and RecommendationUtilization ReviewURRequest for Authorization
References
Case No. ADJ11025609
Regular
Apr 30, 2018

DONNA IVES vs. DR MYERS DISTRIBUTING COMPANY, PREFERRED EMPLOYERS INSURANCE COMPANY

In this workers' compensation case, the Appeals Board rescinded the WCJ's decision and returned the matter for further proceedings. The Board found that the defendant improperly modified the applicant's Request for Authorization (RFA) for treatment by a chiropractic neurologist. Instead of referring the request for medical utilization review, the claims administrator authorized treatment with a general chiropractor. The Board emphasized that claims adjusters cannot modify RFAs and that medical necessity decisions must be made by physicians.

WCABPetition for ReconsiderationFindings of FactWCJindustrial injurychiropractic neurologistMedical Provider Network (MPN)Request for Authorization (RFA)Utilization Review (UR)Medical Treatment Utilization Schedule (MTUS)
References
Case No. ADJ982471 (LAO 0859620)
Regular
Apr 28, 2014

JUVENCIO TORRES-RAMOS vs. FELIX MARQUEZ, REDWOOD FREE INSURANCE COMPANY, BERKSHIRE HATHAWAY

The Workers' Compensation Appeals Board denied the defendant's petition for removal and dismissed the applicant's petition for reconsideration. The Board adopted the WCJ's report, finding that the defendant failed to show significant prejudice or irreparable harm to warrant removal. The applicant voluntarily withdrew their reconsideration petition after understanding that their pain management treatment request lacked the required authorization form. The case was referred to the Independent Medical Review (IMR) process for a decision on the applicant's need for pain management treatment.

WCABPetition for RemovalPetition for ReconsiderationIndependent Medical ReviewIMRsubstantial evidenceutilization reviewtimelyprimary treating physicianDWC Form PR-2
References
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
Case No. ADJ8833224
Regular
Feb 21, 2017

JOHN WEIMER vs. HILLYARD, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board found that an incomplete Request for Authorization (RFA) with an incorrect claim number was submitted on September 19, 2016. Despite the error, the RFA successfully identified the employee and triggered the defendant's duty to conduct utilization review on that date. Consequently, the defendant's utilization review denial on September 29, 2016, was deemed untimely, invalidating the denial. The case was returned for further proceedings to determine the necessity of the requested medical treatment.

DWC RFAUtilization ReviewTimelinessClaim NumberIncomplete RequestMedical TreatmentReconsiderationAdministrative Director RuleTreating PhysicianClaims Adjuster
References
Case No. ADJ15763825
Regular
Sep 16, 2025

CLAUDIO CARDOZO vs. ROCK AND ROLL CAR WASH, REDWOOD FIRE AND CASUALTY INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by Redwood Fire and Casualty Insurance Company dba Berkshire Hathaway Homestate Companies. The petition challenged a lien trial decision concerning a medical-legal evaluation performed by Dr. Michaels of Premier Psychological Services. The WCJ found that a medical dispute regarding psyche existed at the time of the evaluation, Dr. Michaels was validly designated as the Primary Treating Physician, and the evaluation was not barred by the 60-day rule for new claims as it was an amendment to an already accepted claim. The Appeals Board adopted the WCJ's reasoning and denied the petition.

Workers' Compensation Appeals BoardPetition for ReconsiderationLabor Code Section 5909Adjudication NumberOpinion and Order Denying PetitionWCJ ReportEAMS TransmissionNotice of TransmissionProof of ServiceFindings and Order
References
Case No. ADJ8917716
Regular
May 03, 2016

INGA CZECH vs. BANK OF AMERICA, ACE AMERICAN INSURANCE COMPANY

Defendant Bank of America sought reconsideration of an award for medical treatment, arguing the Request for Authorization (RFA) was improperly served on their attorney, not the adjuster, thus not triggering utilization review timelines. The Workers' Compensation Appeals Board denied reconsideration, affirming that the applicant's physician's requested treatment was reasonable. The Board held that when an attorney receives an RFA and the defense has objected to its receipt, the attorney has a duty to transmit it to the claims administrator to fulfill the duty of good faith investigation. Therefore, the defendant's failure to process the treatment request after receiving it through their attorney resulted in liability for the awarded medical care.

Workers Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Request for Authorization (RFA)Declaration of Readiness to Proceed (DOR)Expedited HearingAdministrative Law Judge (WCJ)Agency LawAttorney NegligenceGood Faith Investigation
References
Case No. ADJ339088 (SDO 0304788)
Regular
Aug 30, 2016

Gregory Parrent vs. SBC-PACIFIC BELL TELEPHONE COMPANY

This case clarifies the utilization review (UR) and independent medical review (IMR) process for medical treatment recommendations within a Medical Provider Network (MPN). The Appeals Board affirmed that even when a physician is part of the defendant's MPN, their treatment recommendations are subject to UR by the employer if disputed. If UR denies or modifies the recommendation, the dispute must then proceed to IMR, not the Appeals Board. The applicant's contention that MPN physicians' recommendations are exempt from UR was rejected, emphasizing a uniform standard of care and review for all medical treatment.

Workers' Compensation Appeals BoardSBC-Pacific Bell Telephone CompanySedgwick Claims Management ServicesPetition for ReconsiderationMedical Provider Network (MPN)Independent Medical Review (IMR)Utilization Review (UR)Labor Code section 4600primary treating physicianRequest for Authorization (RFA)
References
Case No. ADJ17686288
Regular
May 07, 2025

VICTOR CRUZ vs. CHANNEL DEVELOPMENT, INC.; PREFERRED PROFESSIONAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration regarding an award of further and continuing medical treatment for applicant Victor Cruz at the Centre for Neuro Skills. The defendant argued that the WCJ lacked jurisdiction due to a timely RFA denial. However, the Board affirmed the WCJ's decision, finding that the defendant failed to present substantial medical evidence to justify the discontinuation of previously authorized treatment. The decision emphasized the principle that once treatment is authorized, the burden shifts to the defendant to prove a change in circumstances to cease treatment.

Workers' Compensation Appeals BoardVictor CruzChannel DevelopmentInc.Preferred Professional Insurance CompanyOmaha NationalAdjudication Number ADJ17686288Petition for ReconsiderationFindings Order and AwardWCJ
References
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