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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. 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The Workers' Compensation Appeals Board rescinded a prior decision and remanded the case for further proceedings concerning chiropractic treatment for an admitted neck and upper back injury.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
7
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
5
Case No. ADJ10033983 ADJ11112700
Regular
Jul 08, 2019

PABLO PEREZ vs. TAYLOR FARMS, ZURICH NORTH AMERICA INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted applicant Pablo Perez's Petition for Removal, rescinding the prior finding that a Functional Capacity Evaluation (FCE) was not a reasonable and necessary medical-legal expense. The WCAB found that an FCE, recommended by Panel Qualified Medical Evaluator Dr. Ali Soozani to assess permanent impairment, provides crucial objective data not fully captured by subjective complaints or a standard physical examination. The Board reasoned that while a physical therapist conducts the FCE, this is permissible under Labor Code section 3209.5 for medical treatment and does not violate Labor Code section 4628 when viewed as a distinct diagnostic tool supporting the QME's overall evaluation. Consequently, the WCAB issued a new Finding of Fact and Order deeming the FCE reasonable and necessary.

Functional Capacity EvaluationMedical-Legal ExpensePanel Qualified Medical EvaluatorPermanent ImpairmentActivities of Daily LivingSubstantial EvidenceAlmaraz/GuzmanLabor Code Section 4628Diagnostic ToolMedical Opinion
References
4
Case No. ADJ7433042, ADJ7433045, ADJ7433048
Regular
Aug 06, 2013

MARIA GOMEZ vs. HARRIS RANCH BEEF CO., AIMS INSURANCE CO.

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration of a prior decision. The WCJ disallowed the lien claimant's lien for medical treatment, finding that the lien claimant failed to prove the treatment was reasonable and necessary, and its charges were reasonable. The Board affirmed the WCJ's decision, holding that the lien claimant did not meet its evidentiary burden, and denied the petition.

Lien claimantPetition for ReconsiderationJoint Findings of Fact and Ordersubstantial evidencedisallowance of liensCompromise and Releaseuntimely serviceex parte communicationsubstantial medical evidencereasonable and necessary treatment
References
11
Case No. ADJ10555511
Regular
Oct 03, 2018

MARIO GUDINO IBARRA vs. ASHLEY FURNITURE INDUSTRIES, INC., HARTFORD INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC.

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, ruling that Truxtun Pharmacy failed to meet its burden of proof for reimbursement of its lien. The Board found that the pharmacy did not provide substantial medical evidence demonstrating the compound medications were reasonable and necessary under the Medical Treatment Utilization Schedule (MTUS). Specifically, the physician's report lacked necessary citations and the prescribed treatments were not recommended by the MTUS. Therefore, the lien claimant is entitled to no recovery on its lien.

Workers Compensation Appeals BoardAshley Furniture IndustriesHartford Insurance CompanyGallagher Bassett ServicesMario Gudino IbarraTruxtun PharmacyMedical Treatment Utilization ScheduleMTUSOfficial Medical Fee ScheduleOMFS
References
2
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
4
Case No. ADJ2593762 (SAC 0363364)
Regular
Jul 13, 2012

RICHARD HODGE vs. DEPENDABLE HIGHWAY EXPRESS, ZURICH NORTH AMERICA INSURANCE

The Workers' Compensation Appeals Board denied reconsideration, upholding the WCJ's decision to provide psychiatric treatment. Even if the need for psychiatric treatment stems from a potentially non-compensable psychiatric injury, the employer remains liable if the treatment is reasonably required to cure or relieve the effects of a compensable industrial injury. In this case, the applicant's psychiatric treatment was deemed necessary to address cognitive impairment caused by a compensable traumatic brain injury. Therefore, the employer is liable for this treatment under established case law, regardless of the nuances of the six-month employment rule.

Labor Code section 3208.3(d)sudden and extraordinary exceptionsix-month employment rulemedical treatmentLabor Code section 4600reasonably requiredcure or relievenon-compensable injurypsychiatric treatmenttraumatic brain injury
References
6
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. 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
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