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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. 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. ADJ2401554 (FRE 023126)
Regular
Jan 07, 2013

JOSHUA GROSSMAN vs. ARAMARK UNIFORM SERVICE, ACE AMERICAN INSURANCE COMPANY

The Appeals Board granted reconsideration, reversing the judge's decision and finding the defendant liable for self-procured medical treatment. The defendant failed to prove they properly transferred the applicant into their Medical Provider Network (MPN) and neglected or refused to provide reasonable treatment by failing to ensure MPN physician availability. Consequently, the applicant's self-procured treatment from the lien claimant is deemed reasonable and compensable. The defendant is liable for the reasonable cost of this treatment, plus interest and penalties.

MPNself-procured medical treatmentneglect or refusal to provide medical treatmentprimary treating physicianlien claimantreasonable medical treatmentAramark Uniform ServiceAce American Insurance CompanySan Joaquin Accident & Medical GroupKnight v. Liberty Mut. Ins. Co.
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. 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. 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. ADJ8097174
Regular
Jul 01, 2016

JORGE PICENO vs. BRIAN DEVRIES CONSTRUCTION, EVEREST NATIONAL INSURANCE COMPANY, AMERICAN CLAIMS MANAGEMENT, INC.

The defendant sought reconsideration of a Findings and Award regarding nine medical treatment liens. The defendant argued the lien claimants failed to prove reasonableness and necessity of treatment and that penalties/interest were improper. The Appeals Board granted reconsideration, rescinded the prior award, and returned the case to the trial level for further proceedings. This decision was based partly on the Board's error in failing to properly serve all parties.

COMPROMISE AND RELEASEMEDICAL TREATMENTLIEN CLAIMANTSREASONABLENESS AND NECESSITYPENALTIES AND INTERESTMEDICAL PROVIDER NETWORKPANEL QUALIFIED MEDICAL EXAMINERFURTHER PROCEEDINGSFINDINGS AND AWARDPETITION FOR RECONSIDERATION
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. ADJ1448881 (VNO 0460995)
Regular
Sep 06, 2017

CLEMENTE MEJIA vs. PACIFIC MAT, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision disallowing the balance of a lien for medical treatment provided by Dr. Arroyo. The administrative law judge found Dr. Arroyo failed to prove the reasonableness of services beyond progress and permanent and stationary reports, and that he was adequately compensated for reasonable services. The WCAB held that Labor Code section 4600(b), requiring medical treatment to be consistent with the Medical Treatment Utilization Schedule (MTUS) to be considered reasonably required, applied retrospectively to all open cases, including this one. Therefore, the original decision disallowing the remaining portion of the lien was affirmed.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings of FactOrderMedical treatment lienIndustrial injuryCumulative periodPermanent disabilityReasonableness of services
References
Case No. ADJ2460603 (OAK 0348588)
Regular
Aug 03, 2012

JOSE ROGER ABAN vs. CAL CENTURIAN CONSTRUCTION, INC. dba RWR CONSTRUCTION, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration to reverse a prior finding that a lien claimant was entitled to satisfaction of its lien. The Board found that while the defendant may have provided inadequate initial Medical Provider Network (MPN) notices, this deficiency did not result in the applicant being neglected or refused reasonable medical treatment. Because the applicant initially treated within the MPN and did not appear to have trouble accessing care due to the notices, the employer is not liable for self-procured treatment. Therefore, the lien claimant is not entitled to recover on its lien.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Self-procured medical treatmentLien claimantCompromise and ReleaseNeglect or refusal to provide medical treatmentFindings and OrdersPetition for ReconsiderationWCJReport and Recommendation
References
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