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Case Law Database

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

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
0
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 The original order's retrospective utilization review of medical treatment was rescinded because the proceedings lacked essential components like stipulated issues and admitted evidence.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
1
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
6
Case No. ADJ11423609
Regular
Sep 12, 2022

DANIEL SERVIN vs. CERRITOS LEXUS, ACE AMERICAN INSURANCE

This case concerns a defendant's petition for reconsideration of an order authorizing left shoulder surgery. The defendant argued a prior utilization review denial should prevent subsequent authorizations, citing Labor Code section 4610(k). However, the applicant's physician resubmitted the request with additional supporting documentation, triggering a new utilization review. This subsequent review certified the surgery as medically necessary, resolving the medical dispute. The Board denied reconsideration, holding that the defendant voluntarily submitted the resubmitted request, making the February 2, 2022 certification final and precluding further utilization review.

Utilization ReviewFindings and OrderPetition for ReconsiderationMedical NecessityReverse Total Shoulder ArthroplastyRequest for AuthorizationNon-certificationCertificationLabor Code Section 4610Resubmission
References
4
Case No. 2022 NY Slip Op 01011
Regular Panel Decision
Feb 16, 2022

Hamm v. Review Assoc., LLC

The plaintiff, Peter Hamm, an employee, sustained injuries after falling from a ladder while servicing a security system at premises owned by Review Associates, LLC and leased by Fresh Direct, LLC. He initiated a personal injury action alleging common-law negligence and violations of Labor Law §§ 200, 240(1), and 241(6). The Supreme Court initially granted summary judgment to the defendants, dismissing the complaint. On appeal, the Appellate Division modified this order, denying summary judgment for the Labor Law § 240(1) claim against both defendants due to triable issues of fact regarding whether the work constituted "repairs" or "routine maintenance." Additionally, the court denied summary judgment for the common-law negligence and Labor Law § 200 claims against Fresh Direct, LLC, as it failed to establish a lack of notice regarding the defective ladder. The court affirmed the dismissal of the Labor Law § 241(6) claim against both defendants and the common-law negligence and Labor Law § 200 claims against Review Associates, LLC.

Personal InjuryLadder AccidentLabor Law § 240(1)Labor Law § 200Common-law NegligenceSummary JudgmentAppellate DivisionDuty to Maintain Safe PremisesRoutine Maintenance vs. RepairDangerous Condition
References
44
Case No. ADJ380850 (SAL 0117839)
Regular
Apr 26, 2011

Sandra Corona vs. LOS APTOS CHRISTIAN FELLOWSHIP CHILDCARE, CHURCH MUTUAL INSURANCE COMPANY

This case involves a defendant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The original decision awarded the applicant further medical treatment, including a cervical radiofrequency ablation. The defendant argued that the applicant failed to follow the proper Labor Code Section 4062 process after their utilization review denied the treatment request. The majority of the WCAB denied reconsideration, holding that an applicant is not strictly required to use Section 4062 to dispute a utilization review denial and may proceed to an expedited hearing, especially when the employer failed to provide adequate information for the review. However, one commissioner dissented, arguing that Section 4062 mandates a dispute resolution process following utilization review.

Workers' Compensation Appeals BoardLabor Code Section 4610Labor Code Section 4062Utilization ReviewReconsiderationFindings and AwardPrimary Treating PhysicianExpedited HearingAgreed Medical ExaminerQualified Medical Examiner
References
2
Case No. ADJ17821210
Regular
Aug 29, 2025

ROGELIO TOSCANO vs. ELITE EARTHWORKS & ENGINEERING, REDWOOD FIRE & CASUALTY INSURANCE COMPANY

Rogelio Toscano, the applicant, suffered a significant brain injury and has been receiving ongoing outpatient rehabilitation. The defendants attempted to discontinue this care via utilization review, but the Workers' Compensation Appeals Board (WCAB) found this action invalid. The WCAB, adopting the WCJ's report, denied the defendants' petition for reconsideration, affirming that the defendants failed to demonstrate a change of circumstances necessary to justify a new utilization review for previously authorized ongoing treatment. Commissioner Razo dissented, arguing that the majority's reliance on the Patterson rule incorrectly carves out an exception to Labor Code section 4610's utilization review requirements.

Petition for ReconsiderationLabor Code Section 5909Electronic Adjudication Management SystemUtilization ReviewPatterson v. The Oaks FarmNational Cement Co. v. Workers' Comp. Appeals Bd. (Rivota)Allied Signal Aero. v. Workers' Comp. Appeals Bd. (Wiggs)Request for AuthorizationMedical TreatmentBrain Injury Rehabilitation
References
4
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
0
Case No. ADJ7324170, ADJ9797150
Regular
May 10, 2016

Beverly Bolton vs. COUNTY OF SAN BERNARDINO

The Appeals Board granted reconsideration to review the WCJ's finding that the applicant was entitled to requested medical treatment due to the employer's untimely utilization review. The employer argued the request was defective and the review was timely. The Board dismissed the employer's Petition for Removal and, after reconsideration, amended the Findings and Award. The Board affirmed the WCJ's finding that the utilization review was untimely, thus waiving objections to the request, but deferred the issue of medical necessity due to an insufficient record.

Workers Compensation Appeals BoardReconsiderationUtilization ReviewTimelinessRequest for Authorization (RFA)JurisdictionMedical NecessityRemovalAdministrative Law Judge (WCJ)Petition for Removal
References
0
Case No. ADJ6939280
Regular
Nov 08, 2018

ROBIN GONZALEZ vs. FIRST PRESBYTERIAN CHURCH OF SANTA BARBARA, STATE COMPENSATION INSURANCE FUND

This case concerns applicant Robin Gonzalez's claim for ongoing home health care services following a spinal injury. The employer's insurer denied these services via a timely Utilization Review (UR) based on the Medical Treatment Utilization Schedule (MTUS). The Workers' Compensation Appeals Board (WCAB) affirmed the trial judge's decision, holding that the WCAB lacks jurisdiction to review the UR denial because the process was timely and the dispute over medical necessity must be resolved through the Independent Medical Review (IMR) process, as established in Dubon II. Applicant's treating physician can submit a new request if medically necessary, as the prior UR denial is effective for 12 months.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewMedical Treatment Utilization ScheduleJurisdictionHome Health CarePermanent DisabilityPetition to ReopenFailed Back SyndromeDubon II
References
6
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