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

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In this workers' compensation case, the Appeals Board rescinded the WCJ's decision and returned the matter for further proceedings.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. ADJ2128084 (VNO 0428792) ADJ1712801 (VNO 0428794) ADJ346332 (VNO 0428790) ADJ6882145

Regular

Feb 07, 2017

NAYER GARAS vs. RXI PLASTICS, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board rescinded the WCJ's order for continuing home health care, finding the record insufficient to support the decision. Although the parties stipulated to timely utilization review denials, the specific RFAs forming the basis for these denials were not adequately documented in the record. The Board determined it could not ascertain whether the defendant's reliance on UR was inappropriate or if the applicant's care was improperly terminated without a change in circumstances. The case is returned to the WCJ for further proceedings to develop a complete record.

Workers' Compensation Appeals BoardReconsiderationPetition for ReconsiderationHome Health CareUtilization ReviewRequest for AuthorizationTreating PhysicianAdministrative Law JudgeLiver TransplantMedical Necessity

References

Case No. ADJ9426340 ADJ9182419

Regular

May 18, 2016

ANTHONY FISHER vs. PUTNAM LEXUS, PUBLIC SERVICE MUTUAL INSURANCE COMPANY, CORVEL CORPORATION

This case concerns applicant Anthony Fisher's claim for stem cell treatment for his knees. The primary treating physician submitted Requests for Authorization (RFAs) which the defendant argued were never received. The Workers' Compensation Appeals Board (WCAB) rescinded the prior denial, finding the exclusion of applicant's witness testimony (Sarina Brown) was an error. The matter is returned to the trial level to admit Ms. Brown's declaration and allow both parties to present further evidence regarding RFA transmission and the medical necessity of the treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderRequest for Authorizationmesenchymal Adipose derived stem cellutilization reviewAgreed Medical Evaluatordeclaration of Sarina Brownhearsaydue process

References

Case No. ADJ8458980

Regular

Dec 10, 2018

ELENA ESPINOZA vs. PLY GEM PACIFIC WINDOWS, ZURICH NORTH AMERICA

This case concerns a lien claimant seeking reimbursement for durable medical equipment (DME) provided to applicant Elena Espinoza. The Workers' Compensation Appeals Board (WCAB) affirmed the administrative law judge's decision disallowing the lien. The WCAB found that the lien claimant failed to submit proper Requests for Authorization (RFAs) from the applicant's treating physician for the DME. Furthermore, even after receiving a non-certification notice from the defendant, the lien claimant did not follow the proper statutory procedures to dispute the utilization review decision. Therefore, the WCAB concluded the lien claimant did not meet its burden of proof.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantDurable Medical Equipment (DME)Request for Authorization (RFA)Utilization Review (UR)Findings and Order (F&O)Compromise and ReleasePrimary Treating Physician's Progress Report (PR-2)Retro-authorization

References

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

NAYER GARAS vs. RXI PLASTICS, INC., STATE COMPENSATION INSURANCE FUND

ANTHONY FISHER vs. PUTNAM LEXUS, PUBLIC SERVICE MUTUAL INSURANCE COMPANY, CORVEL CORPORATION

ELENA ESPINOZA vs. PLY GEM PACIFIC WINDOWS, ZURICH NORTH AMERICA