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

Case No. ADJ2772961 (VNO 0505212)
Regular
May 20, 2011

Rodney Elkins vs. DE MOOR'S PAINTING, INC., STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration to clarify that the applicant's treating physician, not the Agreed Medical Evaluator, must direct and manage the decreasing narcotic treatment plan. The Board affirmed the award of a gym membership, exercise sessions, and sleep medication, finding these consistent with the AME's well-reasoned opinion and the treating physician's recommendations. The issue of radiofrequency nerve ablation was deferred as premature pending completion of the current treatment plan. Finally, the Board denied attorney fees under Labor Code section 5814.5, finding no unreasonable delay in compensation due to the defendant's reliance on the AME's medical opinion.

Workers' Compensation Appeals BoardAgreed Medical EvaluatorTreating PhysicianPetition for ReconsiderationFindings of Fact and AwardLabor Code Section 5814.5Medical TreatmentRadiofrequency Nerve AblationNarcotic AnalgesicsGym Membership
References
7
Case No. ADJ380850 (SAL 0117839)
Regular
Apr 26, 2011

Sandra Corona vs. LOS APTOS CHRISTIAN FELLOWSHIP CHILDCARE, CHURCH MUTUAL INSURANCE COMPANY

This case involves a defendant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The original decision awarded the applicant further medical treatment, including a cervical radiofrequency ablation. The defendant argued that the applicant failed to follow the proper Labor Code Section 4062 process after their utilization review denied the treatment request. The majority of the WCAB denied reconsideration, holding that an applicant is not strictly required to use Section 4062 to dispute a utilization review denial and may proceed to an expedited hearing, especially when the employer failed to provide adequate information for the review. However, one commissioner dissented, arguing that Section 4062 mandates a dispute resolution process following utilization review.

Workers' Compensation Appeals BoardLabor Code Section 4610Labor Code Section 4062Utilization ReviewReconsiderationFindings and AwardPrimary Treating PhysicianExpedited HearingAgreed Medical ExaminerQualified Medical Examiner
References
2
Case No. SAL 0048019
Regular
May 28, 2008

CONN TRENNER vs. MONTEREY PENINSULA AIRPORT DISTRICT, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration, reversing the finding of unreasonable delay in authorizing the applicant's ablation procedure. However, the Board affirmed the finding of unreasonable delay in SCIF's payment of the applicant's co-payment for the procedure, upholding the associated penalty. The matter was returned to the trial level to determine the appropriate attorney's fee award under Labor Code section 5814.5.

Labor Code section 5814Labor Code section 4610Labor Code section 5814.5utilization reviewunreasonable delaypenaltyablation procedureco-paymentreimbursementattorney's fees
References
1
Case No. ADJ3700908 (SRO 0101979) ADJ3874442 (SRO 0098853)
Regular
Jul 18, 2014

Randall Otten vs. Cardinal Newman High School, California Insurance Guarantee Association for Superior National Insurance Company, in liquidation

This case concerns the validity of a Utilization Review (UR) determination regarding the applicant's need for a radiofrequency rhizotomy injection for his low back injury. The Appeals Board reversed the lower judge's decision, finding the UR determination valid. They held that the omission of certain medical reports was not a material procedural defect because they would not have changed the UR physician's conclusion. Furthermore, the Board found the applicant failed to present substantial medical evidence to support the necessity of the treatment or prove the UR was invalid. The issue of medical necessity is now subject to Independent Medical Review (IMR).

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewReconsiderationFindings and AwardMaterial Procedural DefectDubonEvidence-Based GuidelinesAgreed Medical EvaluatorTreating Physician
References
6
Case No. ADJ8920582 (LBO 0029109)
Regular
Oct 10, 2013

DAVID SMITH vs. RMD REBAR, SEABRIGHT INSURANCE COMPANY

This case involves an applicant's claim for workers' compensation medical treatment, specifically facet blocks and a spinal cord stimulator. The Appeals Board affirmed an arbitrator's July 31, 2012 decision, as amended, finding no unreasonable delay in authorizing this treatment after prior related decisions. The Board also affirmed a June 14, 2013 decision by another arbitrator, which imposed a penalty and awarded attorney's fees for defendant's unreasonable delay in authorizing separate treatment (radio frequency ablation). The Appeals Board emphasized the importance of attorney fees to ensure injured workers have recourse for denied medical treatment, even without a monetary award.

Workers' Compensation Appeals BoardReconsiderationAttorney's FeesMedical TreatmentArbitratorFindings and OrderSan FranciscoSeabright Insurance CompanyRMD RebarDavid Smith
References
6
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