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

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
1
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. 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. AHM 127807
Significant
Oct 10, 2006

Bruce Knight, Applicant vs. United Parcel Service, Liberty Mutual Insurance Company

An employer's failure to provide an employee with the required notice of their rights under a Medical Provider Network (MPN) constitutes a neglect or refusal to provide reasonable medical treatment, thereby making the employer liable for reasonable medical treatment self-procured by the employee.

Medical Provider NetworkMPN noticeself-procured treatmentemployer liabilityduty to notifyLabor Code section 4600neglect or refusalreasonable medical treatmenten banc decisionworkers' compensation
References
18
Case No. AHM 127807, AHM 129147
En Banc
Oct 10, 2006

Bruce Knight vs. United Parcel Service, Liberty Mutual Insurance Company

The Appeals Board holds that an employer's failure to provide required notice of rights under a Medical Provider Network (MPN) constitutes a neglect or refusal to provide reasonable medical treatment, making the employer liable for reasonable medical treatment self-procured by the employee.

Medical Provider NetworkMPN noticeself-procured treatmentLabor Code 4600Labor Code 4616employer liabilityinsurer liabilityneglect or refusalreasonable medical treatmentemployee rights
References
18
Case No. ADJ8487806
Regular
Aug 22, 2019

NICOLE CARTER vs. STATE OF CALIFORNIA - DEPARTMENT OF CORRECTIONS - INMATE CLAIMS

The Workers' Compensation Appeals Board affirmed a prior decision disallowing a lien claimant's claim for payment for medical treatment. The Board found that the treating physician's prior opinion, stating the applicant had reached maximum medical improvement and required no further treatment, constituted substantial evidence. Therefore, the lien claimant failed to meet its burden of proving the treatment was reasonably required to cure or relieve the applicant's industrial injury. The Board also noted a lack of evidence regarding the scope of a prior settlement and dismissed arguments about utilization review.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings of Fact and OrderWorkers' Compensation Administrative Law JudgeMedical Provider NetworkUtilization ReviewCompromise and ReleaseLien AddendumPrimary Treating Physician
References
9
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
Case No. ADJ7222696
Regular
Feb 18, 2011

LAWANDA JACKSON vs. UNIVERSAL PROTECTION SERVICE, AMERICAN CASUALTY COMPANY OF REDDING, PENNSYLVANIA

This case involves an applicant seeking treatment outside the defendant's Medical Provider Network (MPN) following a workplace injury. The WCAB granted the defendant's petition for reconsideration, rescinding the prior finding that allowed out-of-network treatment. The Board determined the Administrative Law Judge (ALJ) failed to fully analyze the case under controlling precedent, specifically the *Knight* decision, which requires a finding of "neglect or refusal to provide reasonable medical treatment." The matter is remanded for further proceedings and a new decision by the ALJ, with the Board noting the argument regarding posting requirements under Labor Code section 3550 is particularly persuasive.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNReconsiderationFinding and OrderLabor CodeAdministrative Director RuleNotice RequirementsDue ProcessReport and Recommendation
References
1
Case No. ADJ3796500
Regular
Oct 13, 2010

JEFFREY DIXON vs. FALCON TRADING CO., INC., STATE COMPENSATION INSURANCE FUND

The defendant, SCIF, sought reconsideration of an order requiring them to authorize specific medical treatment for the applicant, which had been denied by utilization review. SCIF argued the applicant failed to follow statutory procedures for dispute resolution regarding medical treatment. However, the Appeals Board denied reconsideration because SCIF waived this procedural defense by not raising it at trial. The sole issue litigated was the reasonableness of the medical treatment, for which the applicant presented substantial evidence. Therefore, the prior order mandating authorization of the treatment was upheld.

Utilization ReviewAgreed Medical ExaminerQualified Medical ExaminerLabor Code Section 4062Labor Code Section 4062.2Declaration of Readiness to ProceedWorkers' Compensation Appeals BoardIndustrial InjuryMedical TreatmentOxycontin
References
15
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