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Case Law Database

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

Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ10896105
Regular
Mar 22, 2018

MICHAEL GHATTAS vs. O'REILLY AUTO PARTS, SAFETY NATIONAL CASUALTY COMPANY

This case concerns whether an employer must authorize requested medical treatment for a denied workers' compensation claim. The Appeals Board denied the applicant's petition for reconsideration, upholding its prior decision. The Board concluded that the employer's timely denial of the claim under Labor Code section 5402 terminated their responsibility to authorize medical treatment. Therefore, the employer was not obligated to submit the physician's request for authorization (RFA) to utilization review despite it being pending when the denial was issued.

Workers' Compensation Appeals BoardPetition for ReconsiderationOpinion and Order DenyingDecision After ReconsiderationFindings of Fact Award and OrderRequest for AuthorizationUtilization ReviewLabor Code Section 5402Claim DenialMedical Treatment Authorization
References
Case No. ADJ2904305 (GOL 0095697) ADJ1827151 (GOL 0095698)
Regular
Aug 02, 2010

GUADALUPE CARRILLO vs. SAN ANTONIO VILLAGE HOA, STATE FARM INSURANCE COMPANIES

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration regarding a disallowed lien balance of $9,349.46. The claimant, a doctor, failed to obtain required written authorization for work hardening services billed under CPT Code 97545. Despite a claim of verbal authorization and a general request for multiple modalities, the Board found the lack of specific written authorization for the disputed services to be determinative. Therefore, the administrative law judge's disallowance of the lien balance was upheld.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationCompromise and ReleaseWork hardeningWork conditioningCPT Code 97545Prior authorizationVerbal authorizationWritten authorization
References
Case No. ADJ1871643 (SDO 0291759)
Regular
Oct 23, 2017

JOSE GOMEZ vs. DEPARTMENT OF CORRECTIONS, REHABILITATION PAROLE & COMMUNITY SERVICES, Legally Uninsured, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, affirming the WCJ's award of medical treatment. The defendant's Utilization Review denial was deemed untimely because their Request for Information was served more than five business days after the initial request, excluding the day after Thanksgiving. The Board clarified that the day after Thanksgiving is considered a normal business day for UR purposes under Labor Code section 4600.4. Therefore, the defendant's untimely RFI did not extend the UR deadline, and the requested medical treatment was properly authorized.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationRequest for InformationTimelinessBusiness DayLabor Code Section 4600.4Petition for ReconsiderationFindings and AwardPrimary Treating Physician
References
Case No. ADJ6909910
Regular
Aug 01, 2017

GILBERTO MORALES vs. HERRICK CORP.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and reversed a prior ruling regarding an epidural steroid injection (ESI). The WCAB found that the defendant's initial authorization for an ESI at the C6-C7 level was not superseded by a subsequent request for a more extensive ESI by a new treating physician. The Board determined there was no documented change in the applicant's medical condition to justify further utilization review of the previously authorized C6-C7 ESI. Therefore, the defendant remains obligated to provide the C6-C7 ESI without additional utilization review.

Epidural Steroid InjectionUtilization ReviewPrior AuthorizationChange of PhysicianCervical SpineWCABPetition for ReconsiderationIndependent Medical ReviewPrimary Treating PhysicianRequest for Authorization
References
Case No. ADJ7685567
Regular
Feb 12, 2015

KATHLEEN O'NEAL vs. HALE ALOHA/MARK ONE CORPORATION, CALIFORNIA SELF-INSURERS' SECURITY FUND

This case involves a dispute over authorization for cervical surgery for applicant Kathleen O'Neal. The defendant argued that Dr. McCormack, who recommended the surgery, was a one-time consultant, not a treating physician, and thus his request for authorization was not subject to utilization review (UR). The Workers' Compensation Appeals Board (WCAB) affirmed the judge's order, finding Dr. McCormack acted as a treating physician by undertaking to obtain authorization and proceed with the surgery. Therefore, the defendant's failure to submit Dr. McCormack's request for authorization to UR in a timely manner meant the UR denial was invalid. The WCAB concluded the defendant was obligated to provide the surgery as it was supported by substantial medical evidence and reasonably necessary.

Utilization ReviewAuthorization RequestTreating PhysicianConsulting PhysicianPrimary Treating PhysicianSecondary Treating PhysicianWorkers' Compensation Appeals BoardAdministrative Director's RuleTimelinessJurisdiction
References
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
Case No. ADJ4261717 (FRE 0227914), ADJ2564944 (FRE 0224116)
Regular
Jan 19, 2017

Ann Swengel vs. CAMBRIDGE; AON CORPORATION, AMERICAN CASUALTY COMPANY OF READING, PENNSYLVANIA

The Appeals Board granted the defendant's petition for reconsideration, reversing the prior order that mandated a gym membership. The Board found that because the defendant timely submitted the request for authorization (RFA) to Utilization Review (UR), the UR's denial is not subject to review by the Board, nor is it subject to Independent Medical Review (IMR) if not timely appealed. Consequently, the applicant's petition for reconsideration and for penalties was denied. The Board emphasized that their jurisdiction regarding UR determinations is limited to timeliness.

Utilization ReviewIndependent Medical ReviewPetition for ReconsiderationFindings of Fact and OrderPrimary Treating PhysicianRequest for AuthorizationAdministrative Director's DeterminationMedical Treatment Utilization ScheduleLabor Code Section 5814.5Stipulations with Request for Award
References
Case No. ADJ8458980
Regular
Dec 10, 2018

ELENA ESPINOZA vs. PLY GEM PACIFIC WINDOWS, ZURICH NORTH AMERICA

This case concerns a lien claimant seeking reimbursement for durable medical equipment (DME) provided to applicant Elena Espinoza. The Workers' Compensation Appeals Board (WCAB) affirmed the administrative law judge's decision disallowing the lien. The WCAB found that the lien claimant failed to submit proper Requests for Authorization (RFAs) from the applicant's treating physician for the DME. Furthermore, even after receiving a non-certification notice from the defendant, the lien claimant did not follow the proper statutory procedures to dispute the utilization review decision. Therefore, the WCAB concluded the lien claimant did not meet its burden of proof.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantDurable Medical Equipment (DME)Request for Authorization (RFA)Utilization Review (UR)Findings and Order (F&O)Compromise and ReleasePrimary Treating Physician's Progress Report (PR-2)Retro-authorization
References
Case No. ADJ9712319
Regular
Jun 20, 2025

ELEANOR DIAZ NEVAREZ vs. ELK GROVE UNIFIED SCHOOL DISTRICT, SCHOOLS INSURANCE AUTHORITY

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by defendant Elk Grove Unified School District. The Board affirmed the WCJ's decision that the utilization review (UR) was untimely and procedurally defective, specifically regarding a Request for Authorization (RFA) for an H-Wave device. The defendant had argued the RFA was incomplete, but the Board found it procedurally complete, thus triggering UR obligations. The Board concluded that the defendant's failure to issue a timely conditional denial, as required by regulations, rendered the UR invalid and untimely. Additionally, the Board confirmed its decision was issued in compliance with the 60-day timeframe stipulated by Labor Code section 5909.

WCABPetition for ReconsiderationLabor Code section 5909TransmissionElectronic Adjudication Management SystemEAMSReport and RecommendationUtilization ReviewURRequest for Authorization
References
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