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Case Law Database

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

Case No. ADJ1718435 (MON 0341690) ADJ2131482 (MON 0340861)
Regular
May 10, 2017

JEROME MITCHELL vs. COMMUTER EXPRESS, GALLAGHER BASSETT

This case involves a lien claimant, RS Medical, seeking reconsideration after its $6,800.28 lien for medical treatment was disallowed by the WCJ. The WCJ found RS Medical failed to prove the treatment was reasonable and necessary for the admitted industrial injuries. The Appeals Board granted reconsideration, finding the WCJ erred by focusing solely on neck treatment when evidence indicated prescriptions were for multiple body parts, including admitted injuries. The matter is returned to the trial level for the WCJ to re-evaluate the medical evidence and determine the reasonableness and necessity of the treatment.

Lien ClaimReconsiderationWCJUtilization ReviewTENS deviceMedical TreatmentBurden of ProofSubstantial EvidenceReasonableness and NecessityIndustrial Injury
References
5
Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
5
Case No. ADJ1812869 (SAC 0356491)
Regular
Nov 10, 2010

DIVINA EMANO vs. UC DAVIS MEDICAL CENTER; Permissibly Self-Insured, Adjusted by SEDGWICK, CMS

This case involves applicant Divina Emano claiming a left carpal tunnel injury against UC Davis Medical Center. The Workers' Compensation Appeals Board granted reconsideration and amended the previous decision. Specifically, Finding of Fact No. 8 was modified to clarify that while no further treatment is needed for the left carpal tunnel injury, other industrial injuries will require reasonable and necessary medical treatment. The Board expressed surprise at the defendant's contention regarding the carpal tunnel injury, noting their prior stipulation and a relevant physician's report.

WORKERS' COMPENSATION APPEALS BOARDDIVINA EMANOUC DAVIS MEDICAL CENTERSEDGWICK CMSOPINION AND ORDERGRANTING RECONSIDERATIONDECISION AFTER RECONSIDERATIONleft carpal tunnel injuryindustrial injuriesWCJ report
References
0
Case No. ADJ8948890
Regular
Oct 07, 2025

ANTONIO COLINDRES vs. PRESTIGE MOTORCOACH CORP.; TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

Lien claimant, Reliable Medical Supply, sought reconsideration of a Findings and Order issued on July 24, 2025, which found that the medical treatment services provided to applicant were not reasonably required to cure or relieve the effects of the industrial injury. Reliable Medical Supply contended that the issue of medical necessity was not raised on the pretrial conference statement. The Appeals Board denied the petition for reconsideration, agreeing with the WCJ that the lien claimant failed to prove the medical treatment services were reasonable and necessary, noting the absence of a DWC Form RFA and lack of MTUS citations in Dr. Shah's report.

Lien ClaimantPetition for ReconsiderationFindings and OrderPretrial Conference StatementMedical Treatment ServicesReasonable and NecessaryBurden of ProofUtilization ReviewMedical Treatment Utilization ScheduleAgreed Medical Evaluator
References
10
Case No. ADJ10033983 ADJ11112700
Regular
Jul 08, 2019

PABLO PEREZ vs. TAYLOR FARMS, ZURICH NORTH AMERICA INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted applicant Pablo Perez's Petition for Removal, rescinding the prior finding that a Functional Capacity Evaluation (FCE) was not a reasonable and necessary medical-legal expense. The WCAB found that an FCE, recommended by Panel Qualified Medical Evaluator Dr. Ali Soozani to assess permanent impairment, provides crucial objective data not fully captured by subjective complaints or a standard physical examination. The Board reasoned that while a physical therapist conducts the FCE, this is permissible under Labor Code section 3209.5 for medical treatment and does not violate Labor Code section 4628 when viewed as a distinct diagnostic tool supporting the QME's overall evaluation. Consequently, the WCAB issued a new Finding of Fact and Order deeming the FCE reasonable and necessary.

Functional Capacity EvaluationMedical-Legal ExpensePanel Qualified Medical EvaluatorPermanent ImpairmentActivities of Daily LivingSubstantial EvidenceAlmaraz/GuzmanLabor Code Section 4628Diagnostic ToolMedical Opinion
References
4
Case No. TI11911166
Regular
Aug 23, 2019

NICOLAS MERCADO vs. PARK WEST ENTERPRISES, INC., dba CO-WEST COMMODITIES, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for ULLICO CASUALTY COMPANY

The Workers' Compensation Appeals Board (WCAB) denied CIGA's petition for reconsideration, upholding its prior decision that an additional bedroom is reasonable and necessary medical treatment for the applicant. The WCAB found substantial medical evidence from Dr. Vasile supports the need for a separate room due to the applicant's quadriplegia and sleep interruptions that worsen his health. While the separate room also benefits the applicant's wife, the WCAB concluded it is medically necessary for the applicant's own treatment and to improve his medical and functional status. The Board affirmed its authority to amend WCJ decisions and found Dr. Vasile's opinion more persuasive than the nurse case manager's.

Workers' Compensation Appeals BoardCIGAReconsideration OpinionHome ModificationAdditional BedroomMedical TreatmentQuadriplegiaTotal Permanent DisabilityPrimary Treating PhysicianDr. Vasile
References
8
Case No. ADJ10555511
Regular
Oct 03, 2018

MARIO GUDINO IBARRA vs. ASHLEY FURNITURE INDUSTRIES, INC., HARTFORD INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC.

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, ruling that Truxtun Pharmacy failed to meet its burden of proof for reimbursement of its lien. The Board found that the pharmacy did not provide substantial medical evidence demonstrating the compound medications were reasonable and necessary under the Medical Treatment Utilization Schedule (MTUS). Specifically, the physician's report lacked necessary citations and the prescribed treatments were not recommended by the MTUS. Therefore, the lien claimant is entitled to no recovery on its lien.

Workers Compensation Appeals BoardAshley Furniture IndustriesHartford Insurance CompanyGallagher Bassett ServicesMario Gudino IbarraTruxtun PharmacyMedical Treatment Utilization ScheduleMTUSOfficial Medical Fee ScheduleOMFS
References
2
Case No. ADJ2754339, ADJ2982695
Regular
Feb 22, 2023

VIRGINA VASQUEZ vs. KING MEAT, INC., FREMONT INSURANCE COMPANY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA)

The Workers' Compensation Appeals Board denied a petition for reconsideration filed by CIGA. CIGA challenged a prior finding that allowed payment for medical treatment and a specific medical-legal report by Dr. Konstat. The Board adopted the Workers' Compensation Judge's report, which found that Dr. Konstat's treatment was reasonable and necessary, and that her 2007 medical-legal report was properly requested. The Board also determined that the prior judge's findings on reasonableness were binding in the subsequent lien trial.

CIGAPetition for ReconsiderationLien ClaimantPrimary Treating PhysicianMedical-Legal ReportsSelf-Procured TreatmentUtilization ReviewLabor Code section 4620Rules 9785(e)(3)Rules 9785(e)(4)
References
4
Case No. TI11980184
Regular
Sep 22, 2015

HEATHER REESE vs. ALL SAINTS HEALTH CARE, STATE COMPENSATION INSURANCE FUND

This case involves a dispute over home health care services for an injured vocational nurse. The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision that denied these services, finding the prior reasoning potentially flawed. The WCAB clarified that household services may be compensable medical treatment if medically necessary and reasonable, citing *Smyers*. Furthermore, new legislation defining home health care as medical treatment and establishing specific requirements also applies. The case is returned to the Administrative Law Judge for further proceedings to develop the record under these clarified legal standards.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact and OrderIndustrial InjuryLumbar SpineCentral Nervous SystemSleep DisorderCardiovascular SystemDeep Vein ThrombophlebitisHome Health Care Services
References
10
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