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

Case No. ADJ4 227596 (POM 0281890) MF ADJ3 720208 (POM 0281889)
Regular
Apr 06, 2016

MARISSA GONZALEZ-ORNELAS vs. COUNTY OF RIVERSIDE

The applicant sought reconsideration of a denied authorization for Synvisc knee injections. The original Independent Medical Review (IMR) denied the request, finding no documentation of the applicant's osteoarthritis failing to respond to conservative treatment. The Appeals Board found this IMR determination was based on a plainly erroneous finding of fact, as medical records in the file directly contradicted this assertion. Therefore, the Board granted the applicant's appeal, rescinded the WCJ's decision, and remanded the case for a new IMR.

Workers' Compensation Appeals BoardIndependent Medical ReviewSynvisc injectionsOsteoarthritisLabor Code section 4610.6(h)Plainly erroneous finding of factOrdinary knowledgeExcess of powersUtilization reviewTreating physician
References
Case No. ADJ3641089
Regular
Jan 25, 2018

JOHN SIGLER vs. GENERAL DYNAMICS, INC., CHARTIS INSURANCE COMPANY, BROADSPIRE CLAIMS SERVICES

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration, upholding the WCJ's decision that he failed to meet his burden of proof for penalties and sanctions. The applicant claimed unreasonable delay and bad faith regarding authorization for Synvisc injections. The Board found the Utilization Review process was timely and, even if it had been delayed by one day, it was not unreasonable, especially since the employer ultimately authorized the treatment. Additionally, the Board affirmed the WCJ's decision to strike an undisclosed exhibit that lacked probative value and was irrelevant to the current claim.

Workers' Compensation Appeals BoardPenalties and SanctionsUnreasonable DelayTreatment AuthorizationUtilization ReviewSynvisc InjectionsPrimary Treating PhysicianRequest for AuthorizationLabor Code Section 5814Labor Code Section 4610
References
Case No. VNO 0504152
Regular
Feb 01, 2008

Debi Surgenor vs. RALPH'S GROCERY COMPANY, SEDGWICK CMS

The Workers' Compensation Appeals Board granted reconsideration to defer the issue of applicant's need for cervical epidural injections due to an inadequate trial record, specifically concerning claim and stipulations for a cervical injury. However, the Board affirmed the original finding that lumbar epidural injections are medically necessary to treat the applicant's industrial injury, supported by medical evidence and demonstrated benefit from prior treatment. The case highlights the importance of a complete and stipulated record for medical treatment claims in workers' compensation proceedings.

Workers' Compensation Appeals BoardRalph's Grocery CompanySedgwick CMSDebi Surgenorcervical epidural injectionslumbar epidural injectionsUtilization Review denialACOEM guidelinesradiculopathyelectrodiagnostic testing
References
Case No. ADJ4043236
Regular
Aug 26, 2010

ELIZABETH MINNIS vs. SANTA BARBARA CHAMBER ORCHESTRA SOCIETY, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration, upholding the administrative law judge's decision to deny a requested epidural steroid injection (ESI). The applicant, injured in 2007, sought a new ESI, claiming prior injections offered temporary relief and avoided more aggressive surgery. However, the Board found insufficient evidence that the proposed ESI was reasonable and necessary, noting the applicant’s pain returned and previous injections provided no substantial relief according to medical evaluations. The Board also noted the applicant had already received multiple ESIs, exceeding typical guideline recommendations, and that surgery had been authorized as an alternative treatment.

Workers' Compensation Appeals BoardReconsiderationEpidural steroid injectionMedical treatmentIndustrial injuryLow backPalliative careSurgeryPhysician's assistantUtilization review
References
Case No. ADJ2969856 (SAL 0073653)
Regular
Apr 01, 2009

PINA vs. MEYER TOMATORES, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, INTERCARE

This case involves a defendant seeking reconsideration of findings that they failed to respond to a request for an epidural injection authorization and that a treating physician provided reasonable and necessary care. The Board dismissed a second petition concerning a WCJ's report, deeming it not a final order. The Board granted reconsideration of the initial petition solely to order the defendant to authorize the epidural injection. All other aspects of the original award were affirmed.

Workers Compensation Appeals BoardPetition for ReconsiderationEpidural InjectionReasonable and Necessary TreatmentUtilization ReviewBoard Rule §10510Floyd Skeren & KellyWCJ Report and RecommendationFinal OrderAggrieved Party
References
Case No. ADJ9126926
Regular
May 09, 2014

TERESA GREGORY vs. CONTRA COSTA COUNTY

Defendant Contra Costa County petitioned for removal to compel a UR physician's testimony regarding a disputed knee injection. The WCJ had ordered the physician to appear for live testimony over defendant's objection. However, at the scheduled hearing, the WCJ removed the case from the calendar, stating the knee injection had already occurred and no pending issues remained. Consequently, the petition for removal was dismissed as moot because the UR physician's testimony was no longer necessary.

Petition for RemovalUtilization ReviewExpedited HearingLive TestimonyWCJMOOTDismissedWorkers' Compensation Appeals BoardRescind OrderGood Cause
References
Case No. ADJ1610169 (ANA 0403916)
Regular
Oct 29, 2010

MARIA ORTEGA vs. USNEYLAND RESORTS; DISNEY

This case concerns a petition for reconsideration by lien claimants challenging the disallowance of their medical liens. The initial administrative law judge disallowed the liens, finding a referral for epidural injections was not supported by evidence. Specifically, the judge noted a report by Dr. Ross, which in turn cited Dr. Trotter's opinion that post-permanent and stationary treatment, including injections, was not appropriate or necessary. The Workers' Compensation Appeals Board denied the petition for reconsideration.

Workers' Compensation Appeals BoardLien ClaimantsPetition for ReconsiderationDisallowed Lien ClaimsCompromise and ReleaseIndustrial InjuryHousekeeperBack InjuryAdministrative Law JudgeFindings and Order
References
Case No. ADJ8115084
Regular
Jun 02, 2014

MARY HAYWORTH vs. KCI HOLDINGS USA, INC., FIDELITY AND GUARANTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, rescinding a prior finding that the applicant failed to establish a plainly erroneous fact in an Independent Medical Review (IMR) determination. The Board found the IMR decision was based on a plainly erroneous mistake of fact because it evaluated a request for dorsal medial branch block injections as though it were a request for facet injections, which are different procedures. Consequently, the medical treatment dispute is remanded to the Administrative Director for review by a different independent review organization or reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.5Plainly Erroneous Finding of FactMedical Treatment DisputeUtilization ReviewAdministrative DirectorDorsal Medial Branch BlockFacet InjectionsMTUS Guidelines
References
Case No. ADJ3568698 (MON 0246436)
Regular
Nov 15, 2016

ROGER SCHENDEL vs. B&B SALES, STATE COMPENSATION INSURANCE FUND

In this workers' compensation case, the applicant sought renewed prescriptions for Norco and Omeprazole. Defendant contested the award of these medications, arguing the Workers' Compensation Appeals Board lacked jurisdiction due to a timely Utilization Review (UR) denial upheld by Independent Medical Review (IMR). The Board denied reconsideration, affirming the WCJ's award based on a stipulation agreement that waived the UR/IMR process in favor of an Agreed Medical Examiner (AME). The majority found defendant bound by the stipulation to abide by the AME's report, which deemed the prescriptions medically appropriate. A dissenting opinion argued the AME's report was insufficient for an award as it was not based on a current examination or complete review of the applicant's medical records.

WCABPetition for ReconsiderationFindings Award and OrdersStipulations with Requests for AwardsNorcoOmeprazoleSynvisc injectionsRequest for Authorization (RFA)Utilization Review (UR) denialIndependent Medical Review (IMR)
References
Case No. SDO 0251396
Regular
May 19, 2008

KENN FINKELSTEIN vs. BUILDERS STAFF CORPORATION, CENTRE INSURANCE COMPANY

The applicant sought reconsideration of a prior Workers' Compensation Appeals Board decision that denied certain medications (Nexium, Lisinopril) and epidural steroid injections, while awarding Lipitor. The Board denied reconsideration, holding that the applicant failed to follow the proper statutory procedure for disputing the employer's utilization review denials. Although there was some question about the validity of the utilization review denial for the injections, the applicant's procedural failure was the decisive factor.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and Award/OrderAdministrative Law Judge (WCJ)Further Medical TreatmentPrescriptive MedicationLipitorNexiumLisinoprilEpidural Steroid Injections
References
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