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

Case No. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
Case No. ADJ1003604 (VNO 0473994)
Regular
May 10, 2016

MARIO CARRASCO vs. CITY OF LOS ANGELES

Lien claimant Western Medical Center (Western) sought reconsideration of an Independent Bill Review (IBR) determination that found no reimbursement warranted for medical services. Western argued the IBR determination was plainly erroneous because the defendant failed to provide a contract justifying payment below the official medical fee schedule. However, the Board dismissed Western's petition, finding it premature and improperly filed. Western failed to exhaust the required statutory appeal process to the Workers' Compensation Appeals Board trial level before filing for reconsideration.

Workers' Compensation Appeals BoardIndependent Bill ReviewAdministrative DirectorMaximus Federal ServicesOfficial Medical Fee ScheduleStipulations and AwardCumulative Trauma InjuryLumbar Spinal SurgerySecond Bill ReviewExplanation of Benefits
References
Case No. ADJ8015232
Regular
Oct 17, 2017

ROSA RAMIREZ vs. RANCHO HARVEST, INC., STAR INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration to determine the validity of a lien for interpreting services. The Board affirmed the lien claimant's entitlement to $1,905.00 for services rendered prior to January 1, 2013. However, they rescinded the original decision regarding services after January 1, 2013, finding them not subject to Independent Bill Review. The case is returned to the trial level to determine the reasonable value of services provided after that date.

Workers' Compensation Appeals BoardLien ClaimantInterpreting ServicesOfficial Medical Fee Schedule (OMFS)Independent Bill Review (IBR)Senate Bill 863 (SB 863)Labor CodeStatute of LimitationsExplanation of ReviewAdministrative Director
References
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
Case No. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
Case No. ADJ7004131
Regular
Apr 09, 2014

ALBERTO BARBOSA vs. GREENHART FARMS, PACIFIC COMPENSATION INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) rescinded the original Findings and Order, returning the case to the WCJ for further proceedings. The WCAB found that the initial decision improperly struck evidence and testimony without sufficient justification. The newly enacted Labor Code Section 5703(j), effective January 1, 2013, regarding vocational expert reports, was deemed applicable to this non-final matter. The WCAB instructed the WCJ to reconsider the vocational expert evidence and applicant's request for medical-legal reimbursement in light of this new statute and relevant case law.

OgilvieHertzDiminished Future Earning CapacityDFECPermanent Disability Rating SchedulePDRSVocational ExpertMedical-Legal ExpensesFindings and OrderF&O
References
Case No. ADJ10348591 ADJ10349019
Regular
Jan 07, 2019

MIGUEL VELAZQUEZ, SERVANDO VELAZQUEZ vs. ARTEMIO ARCE, SOLOMON MARTINEZ

The Workers' Compensation Appeals Board denied a defendant's petition for reconsideration, upholding a prior finding that liens for interpreting services were not barred by AD rule 9792.5.5. This rule, requiring a second review request for fee schedule disputes, did not apply because the interpreter services were not subject to an applicable fee schedule at the time of service. Therefore, the lien claimant's failure to request a second review did not preclude the WCAB from adjudicating the lien dispute. The Board reasoned that AD rule 9792.5.5 and associated statutes only mandate the second review process for disputes concerning amounts under an "applicable fee schedule."

Workers' Compensation Appeals BoardAD Rule 9792.5.5Official Medical Fee ScheduleIndependent Bill ReviewExplanation of ReviewLabor Code section 4603.2Senate Bill 863Threshold IssueFee Schedule DisputeInterpreter Services
References
Case No. ADJ6483062
Regular
Apr 05, 2013

ANITA WASHINGTON vs. STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied Anita Washington's petition for reconsideration of an approved Compromise and Release agreement. The Board found her allegations of fraud regarding SB 863 and its application insufficient due to a lack of specific details. The agreement itself, which dismissed a serious and willful misconduct claim, also stipulated that any potential Civil Code rights were not settled. Consequently, the Board adopted the WCJ's report and denied the reconsideration request.

Petition for ReconsiderationOrder Approving Compromise and ReleasefraudmisrepresentationsSenate Bill 863Civil CodeSerious and Willful PetitionGood Faith Personnel ActionPQMEAME
References
Case No. ADJ3327542, ADJ7143228
Regular
Apr 12, 2018

ABIGAIL FURGOL vs. UCLA MEDICAL CENTER, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves an injured worker, Abigail Furgol, and her employer, UCLA Medical Center. The defendant sought reconsideration, arguing a specific 104-week limit on temporary disability payments from *Brower v. David Jones Construction* should apply. However, the Appeals Board denied reconsideration, finding that the cumulative injury date predates the statutory limit, making *Brower* inapplicable. The Board affirmed that Labor Code section 4650(b), as amended by SB 863, dictates payment calculations from the permanent and stationary date, which was stipulated in this case.

Labor Code § 4656(c)Brower v. David Jones Constructiontemporary disability indemnity104-week limitLabor Code § 4650(b)Senate Bill 863permanent disability indemnitypermanent and stationary dateVillagio Inn & Spa v. Workers' Comp. Appeals Bd. (Soto)cumulative injury
References
Case No. ADJ8381652
Regular
Feb 07, 2014

CARLOS CABRERA RAZO vs. LAS POSAS COUNTRY CLUB, HARTFORD INSURANCE CO.

This case concerns the timeliness of an applicant's strike from a Qualified Medical Evaluator (QME) panel. The Appeals Board vacated its previous grant of reconsideration, dismissed the defendant's Petition for Reconsideration, and denied their Petition for Removal. The Board determined that Labor Code section 4062.2, as amended by SB 863 effective January 1, 2013, applies to pending matters, including this case with a 2012 date of injury. Applying the amended statute and Code of Civil Procedure section 1013(a), the applicant had 15 days from the Administrative Director's assignment of the QME panel to strike a name. The applicant's strike on the 12th day was therefore timely, affirming the Workers' Compensation Judge's decision.

Workers' Compensation Appeals BoardQualified Medical EvaluatorPetition for ReconsiderationPetition for RemovalLabor Code Section 4062.2(c)Senate Bill 863Administrative DirectorCumulative Trauma InjuryQME Panel AssignmentCode of Civil Procedure 1013
References
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