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

Case No. ADJ7817116, ADJ7875974
Regular
Nov 13, 2012

Karen Swanson vs. FRESNO UNIFIED SCHOOL DISTRICT

The Workers' Compensation Appeals Board granted reconsideration to address the defendant's claim that the prior award of medical treatment lacked substantial medical evidence. The Board affirmed the necessity of a Nurse Case Manager, a power-assisted wheelchair, podiatrist visits, and a consultation with Dr. Kodama based on stipulations and medical opinion. However, the Board found insufficient evidence for other requested treatments like physical therapy, home modifications, housekeeping, a wheelchair-accessible van, and social worker visits. Jurisdiction was reserved for these deferred issues pending further development of the medical record, including a home modifications consultation.

WCABAmended Findings and OrderPetition for Reconsiderationsubstantial medical evidenceLabor Code section 4604.5Nurse Case Managerpower-assisted wheelchairpodiatristDr. Kodamadysphagia
References
Case No. ADJ3473190
Regular
Jan 29, 2020

NANCY ARCHIBALD vs. SPELLING ENTERTAINMENT

The Workers' Compensation Appeals Board affirmed a prior award finding applicant sustained injury to her wrists and hands, and that future medical care is subject to utilization review and independent medical review. Applicant argued that her specific treatments were exempt from IMR, citing a past stipulation for her primary treating physician to resolve disputes. However, the Board found the stipulation was not a clear waiver of IMR rights, distinguishing it from prior cases. Applicant also failed to prove defendant unilaterally terminated long-term provision of therapy without justification.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardUtilization Review (UR)Independent Medical Review (IMR)Stipulations with Request for AwardBilateral WristsExecutive Director/AuditorMassage TherapyPilates
References
Case No. ADJ3861984
Regular
Sep 23, 2010

GUADALUPE SANTA CRUZ vs. PEP BOYS, GALLAGHER BASSETT ROSEVILLE

This case involves a lien claim by a chiropractor for over $67,000 for treatment provided to an injured worker. The Workers' Compensation Appeals Board (WCAB) affirmed a prior finding that only $66.94 was owed, disallowing the balance of the lien. The WCAB ruled that a statutory amendment effective in 2008 did not apply retroactively to services rendered prior to its effective date. Additionally, the lien claimant failed to prove licensure for physical and occupational therapy, and the stipulated medical treatment and AME opinions did not cover the disputed past services.

Labor Code section 4604.5(d)(3)retrospective applicationmedical treatment utilizationchiropractic visitsphysical therapy visitsoccupational therapy visitslumbar surgerystipulated awardAME reportsACOEM Guidelines
References
Case No. ADJ563768 (SBR 0331684), ADJ2410618 (SBR 0338943)
Regular
Mar 22, 2010

JORGE GONZALEZ vs. TOYO TIRE USA, TOKO MARINE PASADENA

Lien claimant Access Health Medical Group seeks full reimbursement for services, arguing the WCJ erred by disallowing most of its lien based on anti-referral laws (Labor Code §§ 139.3, 139.31). Access contends these laws do not apply to in-house referrals for chiropractic, acupuncture, or "work conditioning" services, as these are not "physical therapy." The Appeals Board granted reconsideration, finding the WCJ applied an overly broad definition of physical therapy. The case is returned for further proceedings to determine if the billed services were distinct from physical therapy, or if "work conditioning" constitutes physical therapy under the statute.

Labor Code §§ 139.3Labor Code § 139.31anti-referral lawsin-office referralsphysical therapychiropracticacupuncturework conditioninglien claimantFindings and Order
References
Case No. ADJ8266885
Regular
Jan 20, 2016

DAYSI PATRICIA MOLINA ROMERO vs. CALIFORNIA PIZZA KITCHEN, TRAVELERS DIAMOND BAR

This case involves a lien claim by Mario Arroyo, D.C., for chiropractic and physical therapy services provided to an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded the original findings. The WCAB held that "visits" must be distinguished by the type of treatment rendered, allowing for separate reimbursement caps for chiropractic and physical therapy visits. Further development of the record is required to determine the nature of services provided and whether Arroyo is entitled to reimbursement for physical therapy beyond the 24 chiropractic visits already paid.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderLien ClaimantChiropractic VisitsPhysical TherapyLabor Code Section 4604.5(c)(1)Bill ReviewerCumulative TraumaIndustrial Injury
References
Case No. ADJ3033562 (GRO 0024532)
Regular
Jun 27, 2017

Thomas Cullen vs. Atascadero Ford, Inc., State Compensation Insurance Fund

This case concerns the denial of ongoing aqua therapy for applicant Thomas Cullen, who suffered a 1998 work injury resulting in 100% permanent disability and future medical care. The defendant employer and insurer argued their Utilization Review (UR) denial was timely and binding, and that the WCJ misapplied precedent. The Appeals Board affirmed the WCJ's decision to award the aqua therapy, finding the defendant's UR decision invalid due to procedural issues. As a result, the WCJ could properly determine the treatment was reasonable and medically supported by substantial evidence, especially since the applicant's condition worsened when therapy was withdrawn.

Workers' Compensation Appeals BoardReconsiderationAdministrative Law JudgeLabor Code section 5814Patterson v. The Oaks FarmRequest For AuthorizationUtilization Reviewinvalid UR decisionreasonable medical treatmentsubstantial evidence
References
Case No. ADJ4647589
Regular
Dec 10, 2019

ORIS PAYTON vs. CAL EXPO FAIRGROUNDS, CALIFORNIA FAIR SERVICES AUTHORITY

The Workers' Compensation Appeals Board (WCAB) denied the applicant's petition for reconsideration. The applicant sought further physical therapy beyond the statutory limit of 24 visits. The WCAB adopted the Workers' Compensation Administrative Law Judge's report, which concluded that the WCAB lacks the authority to challenge the constitutionality of a statute, including Labor Code section 4604.5, which limits physical therapy visits. Therefore, the applicant's request for treatment exceeding the statutory allowance was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeFindings and AwardIndustrial InjuryCumulative Work ActivitiesMedical TreatmentPhysical TherapyStipulationsAgreed Medical Examiner
References
Case No. ADJ2855195 (VNO 0550470)
Regular
Feb 06, 2014

MARCELO RUEDA vs. DRIVE SERVICE, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration of a WCJ's decision awarding $7,200 for shockwave therapy to the applicant's elbows. The Board found that the lien claimant failed to establish the medical reasonableness and necessity of the treatment, as the Agreed Medical Examiner's opinion did not specifically endorse shockwave therapy. The WCJ's exclusion of the defendant's utilization review denial letters was also questioned, but the Board reopened the record to allow for further development of evidence regarding the treatment's necessity. Consequently, the matter was returned to the trial level for further proceedings and a new decision.

Utilization Reviewshockwave therapymedical necessityAgreed Medical Examinerdeposition testimonydue processdevelopment of recordlien conferencePetition for ReconsiderationFindings and Award
References
Case No. ADJ10265190
Regular
Jun 12, 2017

HANAN MEGALLA vs. COUNTY OF SAN BERNARDINO

This case involves a worker who sustained severe injuries from gunshot wounds and sought additional physical therapy. The defendant employer argued that the request was untimely and beyond the post-surgical treatment period, and that the applicant failed to establish medical necessity. The Workers' Compensation Appeals Board denied the employer's petition for reconsideration, upholding the finding that the employer failed to timely and effectively serve the Utilization Review denial. The Board found the additional physical therapy was reasonable and necessary, and that the request fell within the permissible 24-visit limitation after the post-surgical period concluded.

Workers' Compensation Appeals BoardUtilization ReviewService of DeterminationReconsiderationMedical TreatmentFindings and AwardWCJApplicantDefendantSan Bernardino County
References
Case No. ADJ7568484
Regular
Nov 14, 2014

CHERISH ORANJE vs. CRESTWOOD BEHAVIORAL HEALTH, NATIONAL UNION FIRE INSURANCE COMPANY

This case involves a workers' compensation applicant residing in Nevada who was receiving telephonic therapy from a California-licensed Marriage and Family Therapist. The defendant sought reconsideration, arguing that the telephonic therapy violated Nevada law as the therapist was not licensed in Nevada. The Workers' Compensation Appeals Board denied the petition, holding that California law governs treatment for injuries sustained in California, and the teletherapy in question complied with California's telehealth statutes. The Board concluded that the therapist's location in California while providing services to a Nevada resident did not violate California law, and any potential violation of Nevada law was irrelevant to the California workers' compensation claim.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderMedical TreatmentTelephonic TherapyMarriage and Family TherapistTelemedicine Development ActTelehealth Advancement ActBusiness and Professions CodeSynchronous Interaction
References
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