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

Case No. ADJ9526304
Regular
Oct 22, 2018

GLADYS MELENDEZ vs. MYS CORPORATION/KRYSTAL KLEEN, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Appeals Board granted reconsideration for lien claimant Citywide Scanning Service, finding that the defendant waived their right to object to the reasonableness and necessity of charges by failing to file a timely objection. The Board rescinded the original award and returned the case to the trial level for a determination of reasonable fees for all services. This decision hinged on the interpretation of statutes regarding timely objections to medical-legal expenses. The failure to object within the statutory period precludes defendants from contesting reasonableness and necessity and may expose them to penalties.

Lien claimantPetition for ReconsiderationFindings and AwardWCJExpress Records ManagementPrime Medical ResourcesEmployers' CompensationHollywood Presbyterian Medical CenterClinical Medica San MiguelIndependent Bill Review
References
8
Case No. ADJ4016080 (VNO 0496113)
Regular
Sep 08, 2009

SUZANNE KUYUMDZHYAN vs. JONS MARKETPLACE, ZURICH NORTH AMERICA

The Appeals Board granted reconsideration for both the defendant and lien claimant concerning an Amended Findings and Award. The original decision awarded the lien claimant payment for 18.5 hours of interpreting services, but the defendant argued the lien claimant failed to prove reasonableness and necessity of the services. The Board found the record undeveloped regarding the reasonableness and necessity of Dr. Rahimi's treatment and consequently, the derivative interpreting services. Therefore, the matter is remanded to the trial level for further proceedings to develop the record on these issues.

Workers' Compensation Appeals BoardPetition for ReconsiderationAmended Findings and AwardLien claimantInterpreting servicesCertified interpreterReasonable and necessary treatmentMedical-legal reportsCompromise and ReleaseBurden of proof
References
10
Case No. ADJ166364 (LBO 0297755)
Regular
Jan 21, 2016

BETTY NEAL vs. ROBINSONS-MAY, NATIONAL FIRE & MARINE CASUALTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior order, finding insufficient evidence to support the lien claimant's claim for chiropractic services. The Appeals Board ruled that the lien claimant failed to meet its burden of proving the medical necessity and reasonableness of the treatment provided by Dr. Brady. The case is returned to the trial level for further development of the record, specifically requiring the Agreed Medical Examiner to opine on the reasonableness and necessity of the chiropractic services. The Appeals Board also noted the untimeliness of the lien claimant's opposition, but granted reconsideration on the merits.

Petition for ReconsiderationLien ClaimantPrimary Treating PhysicianIndustrial InjuryCumulative TraumaReasonable and Necessary TreatmentSubstantial Medical EvidenceAgreed Medical ExaminerBill ReviewerPetition to Reopen
References
1
Case No. ADJ873701 (ANA 0299104) ADJ1741214 (ANA 0299113)
Regular
Sep 04, 2018

SHELLEE SMITH vs. SMITH'S FOOD AND DRUG, a subsidiary of the Kroger Company, permissibly self-insured, administered by SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves an untimely denial of a request for zolpidem by the defendant employer. The Workers' Compensation Appeals Board (WCAB) granted reconsideration because the trial judge's decision on medical necessity lacked substantial evidence due to a missing medical report. The matter is returned to the trial level to determine the reasonableness and necessity of the zolpidem treatment based on the correct evidence. The WCAB clarified that even with an untimely denial, the applicant must still prove the medical necessity of the requested treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardZolpidemUtilization ReviewIndependent Medical ReviewRequest for AuthorizationUntimely DenialMedical NecessityBurden of Proof
References
4
Case No. ADJ577900 (STK 0187827)
Regular
Jul 18, 2011

DARIO MEDRANO vs. FEIST CABINETS, VIRGINIA SURETY

The Workers' Compensation Appeals Board granted reconsideration of a prior decision regarding Dr. Brown's medical lien. The Board found that the reasonableness and necessity of Dr. Brown's treatment charges for applicant's 2003 industrial neck and back injury require further review. While defendants failed to properly object to bills, Dr. Brown still bears the burden of proving reasonableness. The case is remanded for the WCJ to determine which specific charges were reasonable and necessary, subject to OMFS, penalties, and interest.

Workers' Compensation Appeals BoardReconsiderationMedical Treatment LienReasonableness and NecessityOfficial Medical Fee ScheduleBurden of ProofIndustrial InjuryCompromise and ReleaseBill ReviewAdministrative Director Rules
References
2
Case No. ADJ3564079 (SDO 0254307)
Regular
Sep 07, 2011

RAUL PEREZ vs. USA WASTE SERVICES, NATIONAL UNION FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration for lien claimant Langlink Interpreters, Inc. (LC) regarding their $\$5,175$ lien for interpreter services. The original judge disallowed the lien, citing lack of proof of necessity, availability of bilingual staff, and pre-authorization. The Board rescinded the original order, returning the case for further proceedings, and established that employers must provide reasonably required interpreter services under Labor Code section 4600. LC now bears the burden to prove services were reasonably required, provided, qualified, and reasonably priced, as per the *Guitron* decision.

Workers' Compensation Appeals Boardlien claimantinterpreter servicesmedical treatmentLabor Code section 4600burden of proofreasonably requiredstipulated Awardpermanent disabilityindustrial injury
References
1
Case No. ADJ900432 (SAC 0323091)
Regular
Dec 30, 2011

MARLENE COPUS vs. NORTH SACRAMENTO ELEMENTARY SCHOOL DISTRICT

This case involves a dispute over the necessity of spinal surgery for an applicant who sustained a cumulative trauma injury to her neck and back. While the applicant's treating physician recommended surgery, a second opinion physician disagreed, citing a lack of nerve root compression. The Appeals Board found that the medical evidence was insufficient to determine the necessity of surgery, particularly in light of ACOEM Practice Guidelines which generally recommend against surgery without nerve root compression. Therefore, the Board rescinded the prior award and remanded the case to appoint an independent physician to evaluate the applicant and determine the reasonableness and necessity of the proposed surgery.

Workers' Compensation Appeals BoardMarlene CopusNorth Sacramento Elementary School Districtcumulative traumaspinal surgerynerve root impingementcervical stenosisDr. OrisekDr. GregoriusACOEM Practice Guidelines
References
4
Case No. 2007 NY Slip Op 30531(U)
Regular Panel Decision
Apr 05, 2007

Schirmer v. Athena-Liberty Lofts, LP

This case is an appeal from an Order of the Supreme Court, New York County, regarding a personal injury action. The plaintiff, a worker at a construction site, sustained injuries, leading to the site owner, Lofts, settling the claim after being found liable under Labor Law § 240 (1). Lofts then pursued indemnity claims against lighting contractor HP and the plaintiff's employer, Burgess. The Appellate Court modified the lower court's decision, vacating the finding that Lofts' settlement amount was reasonable due to Lofts' failure to properly demonstrate reasonableness and its mischaracterization of waiver arguments by HP and Burgess. The Court also affirmed the denial of HP's motion for summary judgment, citing unresolved factual issues concerning inadequate lighting as a cause of the accident.

Personal InjuryConstruction Site AccidentSummary JudgmentIndemnity ClaimLabor Law § 240(1)Appellate DivisionThird-Party ActionSettlement ReasonablenessCross ClaimsInadequate Lighting
References
4
Case No. VNO 0301388
Regular
Sep 05, 2007

JACQUELYN GREEN vs. GENERAL MOTORS CORPORATION, SEDGWICK CLAIMS MANAGEMENT

This case involves an employer's attempt to present non-medical evidence regarding the reasonableness of expenses for an applicant's home elevator. The Appeals Board granted removal, reversing the trial judge's exclusion of these exhibits and witnesses. The Board found that while the medical necessity of the elevator was stipulated, the "reasonable expense" of its installation was a valid issue for which non-medical evidence should be admissible.

removalevidentiary rulingnon-medical exhibitsmedical necessitydue processsubstantial prejudiceirreparable harmpermanent disabilitystipulated awardreasonable expense
References
0
Case No. GRO 23394 GRO 29090
Regular
Mar 18, 2008

LUISA H. GARCIA vs. FOSTER ASSESSMENT, STATE COMPENSATION INSURANCE FUND

The applicant sought reimbursement for a vocational expert's report used to challenge the applicable permanent disability rating schedule. The Appeals Board affirmed the WCJ's finding that the defendant was not liable for the cost of the report because the applicant failed to prove its necessity at the time it was incurred. The Board cited precedent holding that such costs are only reimbursable if reasonable and necessary, and the applicant did not demonstrate necessity for this particular report.

Workers' Compensation Appeals BoardPetition for Reconsiderationpermanent disability rating scheduleLabor Code section 5811reimbursement for costsvocational rehabilitation expertdiminished earning capacityMandatory Settlement Conferenceaffirmative burden of proofjudicial authority
References
1
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