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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. 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. 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. ADJ1128183 (AHM 0122447)
Regular
Apr 19, 2010

MANUEL SOLIS vs. THE QUILTING HOUSE, AMERICAN COMMERCIAL CLAIMS ADMINISTRATION FOR EVEREST NATIONAL INSURANCE

The Workers' Compensation Appeals Board granted reconsideration to overturn a prior ruling that awarded over $32,000 to Psychological Assessment Services (PAS) for applicant Manuel Solis's treatment. The Board found that PAS failed to meet its burden of proof by demonstrating that the extensive psychotherapy services provided were reasonably necessary to cure or relieve the applicant's industrial injury. While affirming the finding of psyche injury, the Board concluded that PAS was entitled to no further reimbursement due to inadequate evidence supporting the necessity and reasonableness of the prolonged treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderIndustrial InjuryBack InjuryShoulder InjuryPsyche InjuryAbdomen InjuryHerniaPsychological Assessment Services
References
2
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
3
Case No. ADJ2855195 (VNO 0550470)
Regular
Feb 06, 2014

MARCELO RUEDA vs. DRIVE SERVICE, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration of a WCJ's decision awarding $7,200 for shockwave therapy to the applicant's elbows. The Board found that the lien claimant failed to establish the medical reasonableness and necessity of the treatment, as the Agreed Medical Examiner's opinion did not specifically endorse shockwave therapy. The WCJ's exclusion of the defendant's utilization review denial letters was also questioned, but the Board reopened the record to allow for further development of evidence regarding the treatment's necessity. Consequently, the matter was returned to the trial level for further proceedings and a new decision.

Utilization Reviewshockwave therapymedical necessityAgreed Medical Examinerdeposition testimonydue processdevelopment of recordlien conferencePetition for ReconsiderationFindings and Award
References
5
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
8
Case No. ADJ8611605 ADJ8611603
Regular
Oct 13, 2017

GILMA DAVILA vs. JOBS METRO NET, ZURICH AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied reconsideration of a decision disallowing a lien claim from Tri-City Health Group. The WCJ found the lien claimant failed to prove the medical treatment was necessary and reasonable. The Board agreed that the lien claimant did not sustain its burden of proof regarding medical necessity, the reasonableness of the services, or entitlement to payment under Labor Code section 5402(c). Furthermore, the Board found no evidence that the alleged injury arose out of and occurred during the course of employment, precluding employer liability for the self-procured treatment.

WCABLien ClaimantPetition for ReconsiderationJoint Findings and OrderWCJMedically Necessary TreatmentLabor Code Section 5402(c)Burden of ProofPrimary Treating PhysicianHealth Insurance Claim Form
References
4
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. 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
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