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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 The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr.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. ADJ9884089
Regular
Feb 03, 2017

Ray Bonilla vs. San Diego Personnel and Employment DBA Good People Employment Services, Zurich American Insurance Company

This case involves a dispute over whether a Medical Provider Network (MPN) physician's recommended treatment requires Utilization Review (UR) before authorization. The Appeals Board rescinded the prior award, holding that MPN second opinion physician recommendations are not exempt from UR. The Board clarified that while MPN dispute resolution exists, it does not preclude the insurer's right to UR. However, the matter was returned for further proceedings to determine if a proper Request for Authorization (RFA) was submitted, as an improperly submitted RFA would relieve the insurer of its UR obligation.

Workers' Compensation Appeals BoardMedical Provider NetworkUtilization ReviewRequest for AuthorizationMPN Second OpinionDWC Form RFAMedical Treatment Utilization ScheduleAdministrative Director's RuleLabor Code Section 4610Independent Medical Review
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
Case No. ADJ11025609
Regular
Apr 30, 2018

DONNA IVES vs. DR MYERS DISTRIBUTING COMPANY, PREFERRED EMPLOYERS INSURANCE COMPANY

In this workers' compensation case, the Appeals Board rescinded the WCJ's decision and returned the matter for further proceedings. The Board found that the defendant improperly modified the applicant's Request for Authorization (RFA) for treatment by a chiropractic neurologist. Instead of referring the request for medical utilization review, the claims administrator authorized treatment with a general chiropractor. The Board emphasized that claims adjusters cannot modify RFAs and that medical necessity decisions must be made by physicians.

WCABPetition for ReconsiderationFindings of FactWCJindustrial injurychiropractic neurologistMedical Provider Network (MPN)Request for Authorization (RFA)Utilization Review (UR)Medical Treatment Utilization Schedule (MTUS)
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. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
Case No. ADJ982471 (LAO 0859620)
Regular
Apr 28, 2014

JUVENCIO TORRES-RAMOS vs. FELIX MARQUEZ, REDWOOD FREE INSURANCE COMPANY, BERKSHIRE HATHAWAY

The Workers' Compensation Appeals Board denied the defendant's petition for removal and dismissed the applicant's petition for reconsideration. The Board adopted the WCJ's report, finding that the defendant failed to show significant prejudice or irreparable harm to warrant removal. The applicant voluntarily withdrew their reconsideration petition after understanding that their pain management treatment request lacked the required authorization form. The case was referred to the Independent Medical Review (IMR) process for a decision on the applicant's need for pain management treatment.

WCABPetition for RemovalPetition for ReconsiderationIndependent Medical ReviewIMRsubstantial evidenceutilization reviewtimelyprimary treating physicianDWC Form PR-2
References
Case No. ADJ8917716
Regular
May 03, 2016

INGA CZECH vs. BANK OF AMERICA, ACE AMERICAN INSURANCE COMPANY

Defendant Bank of America sought reconsideration of an award for medical treatment, arguing the Request for Authorization (RFA) was improperly served on their attorney, not the adjuster, thus not triggering utilization review timelines. The Workers' Compensation Appeals Board denied reconsideration, affirming that the applicant's physician's requested treatment was reasonable. The Board held that when an attorney receives an RFA and the defense has objected to its receipt, the attorney has a duty to transmit it to the claims administrator to fulfill the duty of good faith investigation. Therefore, the defendant's failure to process the treatment request after receiving it through their attorney resulted in liability for the awarded medical care.

Workers Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Request for Authorization (RFA)Declaration of Readiness to Proceed (DOR)Expedited HearingAdministrative Law Judge (WCJ)Agency LawAttorney NegligenceGood Faith Investigation
References
Case No. ADJ10084576
Regular
Oct 06, 2016

ROSE SMITH vs. MEGGITT SENSING SYSTEMS PLC, THE HARTFORD

This case involves Rose Smith's workers' compensation claim where the defendant, Meggit Sensing Systems and its insurer, The Hartford, seek reconsideration of an order allowing Smith to obtain medical treatment outside their Medical Provider Network (MPN). The Appeals Board denied the petition, affirming the WCJ's finding that the defendant's failure to authorize a requested third medical opinion constituted a denial of care. This denial entitled the applicant to seek treatment outside the MPN at the defendant's expense. The defendant argued the request was procedurally deficient and not a request for treatment, but the Board found the failure to respond to the RFA for a third opinion, in context, was a failure to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Request for Authorization (RFA)Petition for ReconsiderationDenial of Medical TreatmentThird Medical OpinionUtilization Review (UR)Primary Treating PhysicianCumulative TraumaLoss of Control
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
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