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

Case No. SJO 0224503
Significant

Scott Kunz vs. Patterson Floor Coverings, Inc., Golden Eagle Insurance Co.

The Board held that a defendant's failure to object to a medical treatment bill on a specific basis, such as lack of medical necessity, under Labor Code section 4603.2, does not constitute a waiver of that objection. The matter was remanded to develop the record on this issue.

Alpine Surgery CentersPatterson Floor CoveringsGolden Eagle InsuranceScott Kunzlien claimfacility feemedical necessityLabor Code section 4603.2Official Medical Fee Scheduleoutpatient surgery center
References
Case No. FRE 0222651
Regular
Jul 15, 2008

CHRISTOPHER HUNT vs. MADERA COUNTY ROAD DEPARTMENT

The Appeals Board granted reconsideration of a WCJ's decision that limited a lien claimant's facility fees to the Official Medical Fee Schedule. The Board found the WCJ erred by not applying the correct *Kunz* standard for determining the reasonableness of outpatient surgery facility fees, which considers factors beyond the fee schedule. The case is remanded for further proceedings to properly develop the record according to *Kunz*.

KunzOfficial Medical Fee Scheduleoutpatient surgery facility feeslien claimantreconsiderationen banc decisionreasonableness of feesusual feegeographical areacontractually negotiated fees
References
Case No. OAK 0314027
Regular
Jul 30, 2007

ANASTACIA MURELLA vs. DEPARTMENT OF INDUSTRIAL RELATIONS / STATE OF CALIFORNIA, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board rescinded a prior order disallowing a lien claim from Bay Surgery Center (BSC) for surgical services. The Board found that the administrative law judge incorrectly applied the *Kunz* standard for evaluating outpatient surgical facility fees and that the issue of BSC's licensure and fictitious-name permit requirements needed further consideration. The case is remanded to the trial level for a new decision that properly addresses these issues, ensuring compliance with *Stokes* and *Kunz*.

KunzFictitious-name permitBurden of proofLien claimantMedical BoardAmbulatory surgical centerMedicare rateLicensed physicianAccreditationUsual fee
References
Case No. ADJ6500027
Regular
Jun 22, 2009

MARK SCOTT vs. SOUTHERN CALIFORNIA EDISON

The Workers' Compensation Appeals Board granted reconsideration of a finding that applicant Mark Scott sustained an industrial injury to his left knee. The Board found that the medical evidence presented, specifically operative reports, lacked any causation analysis and therefore did not substantially support the finding of industrial injury. Consequently, the case was remanded to the trial level for further development of the medical record concerning causation. The Board also deferred ruling on the statute of limitations defense pending this further development.

Workers' Compensation Appeals BoardSouthern California EdisonMark ScottAOE/COEStatute of LimitationsContinuous TraumaCumulative InjuryLabor Code Section 5405Reynolds v. Workers' Comp. Appeals Bd.Statute of Limitations Tolling
References
Case No. ADJ7701496
Regular
Nov 08, 2012

GILBERTO SALDANA vs. SCOTT CHUONG, FARMERS INSURANCE EXCHANGE

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision finding that Scott Chuong was not the applicant's employer when he sustained a back injury while painting Chuong's home. The applicant was instead found to be employed by Filiberto Montano, an unlicensed and uninsured contractor who hired the applicant. The WCAB also imposed $250 in sanctions against the applicant's attorney for frivolous filings and violations of WCAB Rules, finding no good cause to excuse these actions.

Workers' Compensation Appeals BoardGilberto SaldanaScott ChuongFarmers Insurance ExchangeADJ7701496Opinion and Decision After ReconsiderationOrder Imposing SanctionsLabor Code section 5813WCAB Rule 10561Filiberto Montano
References
Case No. ADJ3747523 (POM 0264468)
Regular
Oct 17, 2008

RICHARD E. GONZALES vs. DEPARTMENT OF YOUTH AUTHORITY, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration and rescinded the WCJ's decision, returning the case to the trial level for further proceedings. The Board found the prior decision relied on an improper evidentiary basis by using a stipulation from a nearly identical case to determine the reasonableness of the facility fee. The matter must be re-evaluated with proper evidence and adherence to the guidelines set forth in *Scott Kunz v. Patterson Floor Coverings, Inc.* for determining reasonable facility fees.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFacility FeeReasonable ChargesOfficial Medical Fee ScheduleLabor Code Section 4600Kunz GuidelinesEvidentiary BurdenDiagnostic Arthroscopy
References
Case No. ADJ1372815
Regular
Apr 24, 2009

SCOTT SCHWARTZ vs. WEST COAST WOOD PRODUCTS

This is an order from the Workers' Compensation Appeals Board denying a petition for reconsideration filed by Scott Schwartz. The Board adopted and incorporated the report of the workers' compensation administrative law judge, finding no grounds to overturn the prior decision. The specific reasons for the denial are detailed in the referenced judge's report, which is not provided here. The order was filed on April 24, 2009.

Workers' Compensation Appeals BoardReconsideration deniedAdministrative law judge reportApplicant Scott SchwartzDefendant West Coast Wood ProductsADJ1372815VNO 0267967Order denying reconsiderationPetition for reconsiderationWCJ report adopted
References
Case No. ADJ4638638 [SBR 0299210] ADJ326587 [SBR 0299211] ADJ3373174 [SBR 0312295]
Regular
Dec 19, 2008

, Applicant, MELINDA HATTABAUGH vs. STATE OF CALIFORNIA, CDCR/CALIFORNIA INSTITUTION FOR MEN; Legally Uninsured, STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES, Adjusting Agency

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the denial of over $22,000 in outstanding charges for outpatient surgery services. The lien claimant failed to meet its burden of proof to demonstrate the reasonableness of its charges, as required by Kunz v. Patterson Floor Covering. Defendant's evidence, including expert testimony, supported the finding that the amount paid was reasonable reimbursement.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationOutpatient Surgery CenterBurden of ProofReasonableness of ChargesKunzTapiaFee ScheduleBill Reviewer
References
Case No. VNO 0396976
Regular
Feb 01, 2008

MARIA MARTINEZ vs. STATE OF CALIFORNIA, DEPARTMENT OF SOCIAL SERVICES, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case to the trial level. The WCJ erred by applying the 2004 Outpatient Surgery Center Fee Schedule; instead, the court must determine a reasonable fee based on the *Kunz* precedent. This requires developing the record to consider factors like the provider's usual fees and geographic area rates, not solely the fee schedule.

KunzSB Surgery Centerlien claimantreasonable feeoutpatient surgery center fee scheduleprima facie evidenceWCJAppeals Boardpermanent disabilityfuture medical treatment
References
Case No. POM 263315, ANA 311660, ANA 322880
Regular
Jun 04, 2008

Marta Zarate vs. Blue Banner Company, State Compensation Insurance Fund

The Appeals Board granted reconsideration of a WCJ's decision that allowed a lien claim for outpatient surgery services in full, finding that the record lacked substantial evidence to prove the reasonableness of the fee. The Board rescinded the decision and returned the case to the trial level for further development of the record, emphasizing that the lien claimant bears the burden of proving the reasonableness of its charges. The parties are to present evidence consistent with the *Kunz* decision to establish a reasonable fee for the services.

KunzOfficial Medical Fee Schedulelien claimantreasonable feeoutpatient surgery centerburden of proofprima facie caseusual feegross disproportionateevidentiary record
References
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