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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
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 Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.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
Case No. ADJ9791003
Regular
Feb 21, 2020

FRANKLIN LOPEZ DE LA CRUZ vs. BARRETT BUSINESS SERVICES, INC.

This case concerns a lien claimant, Optimal Health, seeking reimbursement for medical treatment provided to an applicant injured on July 1, 2014. The applicant's employer accepted a lumbar spine injury but denied claims for thoracic spine, cervical spine, and leg injuries. The initial WCJ disallowed Optimal Health's lien, ruling treatment outside the approved Medical Provider Network (MPN) was improper. The Appeals Board granted reconsideration, finding the applicant may self-procure treatment for denied body parts. The Board remanded the case for further proceedings to determine if the applicant sustained injury to denied body parts, if treatment was reasonable and necessary, and if fees were appropriate.

Medical Provider NetworkMPNdenied body partsself-procured treatmentlien claimantburden of proofindustrial injuryreasonable and necessary treatmentMedical Treatment Utilization ScheduleMTUS
References
Case No. ADJ1208276 (VEN 0109627)
Regular
Sep 02, 2016

DANIEL GARCIA vs. PEPSI COLA CO.; SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board rescinded a prior decision and remanded the case for further proceedings concerning chiropractic treatment for an admitted neck and upper back injury. The original decision allowed 16 visits for 2007, deeming them reasonable and necessary, and found the applicant not subject to the 24-visit cap. However, the Board found the Qualified Medical Evaluator's report, used to support the decision, was stale, having been issued ten years prior to the treatment. The Board directed parties to obtain an updated report from the QME, and noted that the defendant failed to conduct utilization review, a proper avenue for disputing treatment reasonableness.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderAdministrative Law JudgeLien ClaimantChiropractic ServicesLabor Code Section 4603.2(b)(2)PenaltiesSanctionsReasonable and Necessary Treatment
References
Case No. ADJ4028210 (SJO 0251585)
Regular
Apr 06, 2009

JENNY PHAM vs. SANMINA-SCI CORPORATION, SENTRY CLAIMS SERVICE

This case concerns a dispute over the reasonableness and necessity of chiropractic and acupuncture treatment provided to an applicant for an industrial injury. The defendant argues the treatment exceeded the ACOEM Guidelines and was not evidence-based. The Appeals Board granted reconsideration, finding the WCJ's prior decision allowing the lien premature. The Board rescinded the decision and returned the case for further development of the medical record to determine if the treatment complied with the ACOEM Guidelines. The defendant's petition for removal was dismissed as moot.

Petition for RemovalPetition for ReconsiderationFindings and OrderCompromise and ReleaseIndustrial InjuryNeck InjuryBilateral ShouldersReasonable and Necessary TreatmentACOEM GuidelinesLabor Code Section 4600
References
Case No. ADJ6490669
Regular
Sep 05, 2012

FELIX CHAVEZ vs. T.D. HAYES COMMUNICATIONS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied reconsideration of a decision concerning applicant Felix Chavez's claim. The Board upheld the judge's credibility findings and admonished lien claimants for procedural missteps. Importantly, the Board clarified that an employer's alleged failure to properly notice their Medical Provider Network (MPN) does not automatically obligate them to reimburse self-procured treatment outside the MPN if reasonable treatment was not neglected or refused. Furthermore, the lien claimants failed to prove the necessity and reasonableness of the claimed medical services and costs.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeMedical Provider Network (MPN)Self-Procured TreatmentNotice RequirementsNeglect or RefusalReasonable Medical TreatmentBurden of ProofReasonably Required Treatment
References
Case No. ADJ8035089, ADJ8033530, ADJ8033513
Regular
Jun 27, 2012

Linda Barajas vs. First Group America, Chartis

The Appeals Board overturned a WCJ's denial of reimbursement for a self-procured gym membership. The applicant's claim was in delay status when her physician prescribed the membership, and she notified the adjuster without objection before purchasing it. The Board found the gym membership reasonable and consistent with ACOEM guidelines for shoulder treatment, though limited to six months. Therefore, the applicant is awarded one-half the cost of her 12-month membership as reasonable self-procured medical treatment.

Workers' Compensation Appeals BoardReconsiderationSelf-procured medical treatmentGym membershipTreating physicianDelay statusACOEM guidelinesLabor Code 5402(c)Utilization reviewIndustrial injury
References
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
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
Case No. ADJ1624085
Regular
May 28, 2013

ALICIA CASTILLO vs. NATIONAL O-RING, AMERICAN HOME ASSURANCE, CHARTIS, LIBERTY MUTUAL

The Workers' Compensation Appeals Board (WCAB) granted the lien claimant's petition for reconsideration, rescinding the original decision that disallowed the lien. The WCAB found that the medical record needed further development, specifically regarding whether the treatment provided by the lien claimant was reasonable and necessary, as this was not explicitly addressed by the Agreed Medical Evaluator (AME). The case was returned to the administrative law judge for further proceedings and a new decision. Commissioner Moresi dissented, arguing that the lien claimant failed to meet their burden of proof for the reasonableness and necessity of the treatment provided.

Lien ClaimantPetition for ReconsiderationFindings and OrderReasonable and Necessary TreatmentAgreed Medical EvaluatorPrimary Treating PhysicianCumulative Trauma InjuryCompromise and ReleaseBurden of ProofMedical Treatment Lien
References
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