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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. 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 The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely.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. RDG 0115958
Significant
Nov 16, 2004

Brice Sandhagen, Applicant vs. Cox & Cox Construction, Inc.; State Compensation Insurance Fund

The Appeals Board held that the utilization review time deadlines are mandatory; if a defendant fails to meet these deadlines, any utilization review report is inadmissible, and the defendant must use the AME/QME procedure as the objecting party.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Time DeadlinesAdmissibility of EvidenceMedical Treatment RecommendationACOEM GuidelinesAgreed Medical EvaluatorQualified Medical EvaluatorSection 4062
References
Case No. ADJ13656596
Regular
Mar 04, 2025

CARLOS CARTAGENA vs. ORION ORNAMENTAL IRON, INC.; CYPRESS INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) denied the Petition for Reconsideration filed by Cypress Insurance Company. The petition challenged a Findings and Order from November 26, 2024, which found in favor of a lien claimant, DENTAL TRAUMA CENTER. The defendant argued that the lien claimant failed to timely submit billing and that there was insufficient evidence for the dental injury. Additionally, the defendant sought retrospective utilization review. The WCAB, adopting the WCJ's report, upheld the original decision, citing that the lien claimant's billing was timely served on a co-defendant, that exceptions to the 12-month billing rule apply when a claim is initially denied as non-industrial, and that the defendant failed to present medical evidence to rebut the applicant's medical opinions. The WCAB also denied retrospective utilization review due to the defendant's initial failure to medically investigate the disputed body part.

Workers' Compensation Appeals BoardPetition for ReconsiderationLabor Code section 5909Electronic Adjudication Management SystemEAMSTransmission to Appeals BoardAD Rule 9792.9Utilization ReviewURDeferral of Utilization Review
References
Case No. ADJ12511409
Regular
Jun 18, 2025

JOSE LOPEZ FRANCO vs. JDMC MEDINA CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

Applicant Jose Lopez Franco sought reconsideration of a WCJ's decision finding that his Request for Authorization (RFA) did not qualify for expedited review and was timely decided, thus precluding WCAB jurisdiction over a medical treatment dispute. The Appeals Board granted reconsideration, finding that the evaluation of whether an RFA requires expedited review is an inherently medical determination and must be made by a medical professional within the 72-hour expedited review timeframe. As defendant's Utilization Review provider failed to do so, the Board concluded that the UR decision was untimely, vesting the WCAB with jurisdiction. The matter was rescinded and returned to the trial level for a determination of medical necessity.

Request for AuthorizationExpedited ReviewUtilization ReviewTimelinessMedical NecessityImminent ThreatAdministrative Director RuleLabor CodeWorkers' Compensation Appeals BoardFindings of Fact
References
Case No. ADJ7803069
Regular
Mar 22, 2016

EDILBERTO CERNA ROMERO vs. STONES AND TRADITIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and reversed the judge's finding regarding a September 14, 2015 utilization review (UR) decision. The Board found this second UR decision, which sought further information on some treatments, to be timely for all requested modalities. Consequently, the Board ruled that the UR decision of September 14, 2015, was timely, and the WCJ lacked jurisdiction to review the medical necessity of the denied treatments. The Board did not disturb the WCJ's finding that the August 12, 2015 UR decision was untimely.

Utilization ReviewTimelinessLabor Code Section 4610Request for AuthorizationDWC Form RFAIndependent Medical ReviewMedical NecessityProspective ReviewConcurrent ReviewAppeals Board
References
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. ADJ726676
Regular
Jan 27, 2010

JACQUELYN LEONARD vs. SANTA MARIA BONITA SCHOOL DISTRICT, WORKERS' COMPENSATION ADMINISTRATORS

This case involves a lien claimant seeking reconsideration of a disallowed lien for medical equipment. The Appeals Board found the WCJ erred in disallowing the lien solely because the equipment was provided before authorization. The Board remanded the case for further proceedings to address unresolved factual and legal issues regarding the utilization review process, the role of the prescribing physician, and compliance with procedural rules for requesting authorization. The Board emphasized that "retrospective review" is permitted under Labor Code section 4610(g)(1).

Workers' Compensation Appeals BoardReconsiderationLienUtilization ReviewLabor Code section 4610Retrospective reviewRequest for AuthorizationDoctor's First ReportRS-41 deviceQME
References
Case No. ADJ12508080
Regular
Dec 18, 2020

JANE YOVINO-YOUNG vs. AMADOR RESIDENTIAL CARE, STATE NATIONAL INSURANCE COMPANY

This case concerns the timeliness of utilization review (UR) decisions in a workers' compensation claim. The applicant argued that UR decisions were untimely communicated due to discrepancies between proofs of service and postal dates. However, the Workers' Compensation Appeals Board (WCAB) denied reconsideration. The WCAB found that since the UR decisions were communicated via facsimile, the stricter two-business-day rule for written notice did not apply. Furthermore, the WCAB held that it is not bound by Code of Civil Procedure rules regarding the validity of proofs of service in this context. Ultimately, the WCAB affirmed the administrative law judge's finding that the UR decisions were timely communicated.

Utilization ReviewTimely CommunicationProof of ServicePostage Date StampFindings and OrderPetition for ReconsiderationPrimary Treating PhysicianRequest for AuthorizationIndependent Medical ReviewMedical Necessity
References
Case No. ADJ10000461
Regular
Sep 03, 2019

MARIA SOTO vs. ATHERTON BAPTIST HOMES, INSURANCE COMPANY OF THE WEST, CYPRESS INSURANCE COMPANY

The Appeals Board granted the lien claimants' petition for reconsideration due to a lack of a proper trial record. The original order's retrospective utilization review of medical treatment was rescinded because the proceedings lacked essential components like stipulated issues and admitted evidence. The case is returned to the WCJ for further proceedings to establish a complete record. The Board noted potential issues regarding timely service and the applicability of utilization review to lien claimants.

Petition for ReconsiderationLien ClaimantsUtilization ReviewRetrospective Utilization ReviewTrial RecordMinutes of HearingSummary of EvidenceStipulationsAdmitted EvidenceCompromise and Release
References
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