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

Case No. ADJ10061866
Regular
Jun 20, 2016

MARK CRONIN vs. CITY OF LOS ANGELES

Here's a summary of the case for a lawyer: The Workers' Compensation Appeals Board denied reconsideration of a decision finding a late Independent Medical Review (IMR) determination valid. The Board ruled that timeframes for IMR issuance are directory, not mandatory, and a late IMR does not invalidate the determination. Therefore, the applicant cannot object to the IMR's timeliness after it has been issued. The Board followed precedent holding that untimeliness of an IMR does not invalidate it, thus an objection on that basis is waived.

Workers' Compensation Appeals BoardIndependent Medical ReviewIMRuntimely IMRreconsiderationmedical treatment disputeLabor Code section 4610.6(d)directory timeframesmandatory timeframesutilization review
References
37
Case No. ADJ3223915
Regular
Aug 08, 2016

Francisco Correa vs. ANDIAMO, INC., STATE COMPENSATION INSURANCE FUND

This case concerns a dispute over applicant Francisco Correa's prescription for Zanaflex. Initially, the Workers' Compensation Appeals Board (WCAB) rescinded a prior decision that invalidated Independent Medical Review (IMR) determinations, finding that IMR timeliness is directory, not mandatory. However, upon reconsideration, the WCAB recognized that the prior decision failed to address unchallenged findings that the IMRs were substantively defective. Consequently, the WCAB is now remanding the case to the Administrative Director for a new IMR, finding that the applicant's appeal of the original IMR determinations is valid.

Independent Medical ReviewIMRMedical Treatment Utilization ScheduleMTUSZanaflexLabor Code section 4610.6Stevens v. Workers' Comp. Appeals Bd.Administrative DirectorUtilization ReviewPetition for Reconsideration
References
11
Case No. ADJ8588048
Regular
Jul 18, 2018

KELLY LUHMANN vs. TORRANCE UNIFIED SCHOOL DISTRICT

This case concerns a worker's compensation applicant who sought reconsideration of a decision upholding the denial of an MRI for a knee injury. While the administrative law judge initially found the Independent Medical Review (IMR) determination untimely, the Workers' Compensation Appeals Board (WCAB) clarified that the IMR was issued within the statutory timeframe after receiving supporting documentation. Crucially, the WCAB noted that even if the IMR were late, timeliness is not grounds for appeal, and a delay does not invalidate the IMR decision based on established case law. Therefore, the applicant is bound by the IMR's decision denying the MRI, and the petition for reconsideration was denied.

Independent Medical ReviewUtilization ReviewLabor Code Section 4610.6TimelinessSupporting DocumentationDirectory vs. Mandatory Time PeriodMedical NecessityMRIKnee InjuryPsyche Injury
References
4
Case No. ADJ9920940
Regular
Apr 14, 2016

ROBERT TOM vs. BUILDING AND COMPUTER ELECTRIC, INC.; REPUBLIC UNDERWRITERS INSURANCE, administered by SEDGWICK CMS, INC.

This case concerns a dispute over the timeliness of an Independent Medical Review (IMR) determination. The applicant argued the IMR was untimely, granting the Workers' Compensation Appeals Board (WCAB) jurisdiction to review the medical treatment dispute. The WCAB reviewed the evidence and found no clear and convincing proof that the director violated statutory timelines in issuing the IMR determination. Therefore, the WCAB affirmed the original decision finding the IMR to be timely.

IMRPetition for ReconsiderationFindings and OrderUtilization ReviewAdministrative DirectorStatutory TimeframeLabor Code Section 4610Labor Code Section 4610.6ADR 9792.10.5(a)(1)Burden of Proof
References
0
Case No. ADJ4001054 (SAC 0153565)
Regular
Jul 02, 2016

MARYANN MAYFIELD-WEIGANT vs. ROSEVILLE COMMUNITY HOSPITAL, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for BEAVER INSURANCE, a subsidiary of FREMONT COMPENSATION, in liquidation

This case concerns a worker's appeal of two Independent Medical Review (IMR) denials for prescription medication and lumbar surgery. The Administrative Law Judge (ALJ) found insufficient evidence to overturn the IMR decision for medication and noted the surgery IMR was late but upheld its validity. The Workers' Compensation Appeals Board denied reconsideration, affirming the ALJ's decision. They held that the timeliness of an IMR determination is directory, not mandatory, and therefore does not invalidate the decision, citing precedent.

Independent Medical ReviewIMRPetition for ReconsiderationWorkers' Compensation Appeals BoardWCJLumbar spine injuryUtilization reviewPrescription medicine authorizationLumbar surgery authorizationPlainly erroneous
References
4
Case No. ADJ8858239, ADJ8858240
Regular
Oct 13, 2016

ANTOINETTE MIRANDA vs. CALIFORNIA DEPARTMENT OF CORRECTIONS, legally uninsured

This case concerns the timeliness of an Independent Medical Review (IMR) determination for a left knee total arthroplasty. The WCJ found the IMR determination was late and the WCAB had jurisdiction, but denied the surgery due to insufficient evidence of medical necessity. The Appeals Board granted reconsideration, affirming the denial of treatment but clarifying that the timeframe for IMR issuance under Labor Code section 4610.6(d) is directory, not mandatory. Therefore, the late IMR determination is valid, and the applicant is bound by its decision regarding the medical necessity of the proposed surgery.

Independent Medical ReviewUtilization ReviewLabor Code Section 4610.6(d)Directory vs. Mandatory TimeframeMedical NecessityLeft Knee Total ArthroplastyWCJWCABPetition for ReconsiderationReport and Recommendation
References
4
Case No. ADJ1939880 (LAO 0865897) ADJ1112153 (LAO 0868868)
Regular
Mar 06, 2014

ANTONIO GARCIA VASQUEZ vs. BAGUETTE WORLD, STATE COMPENSATION INSURANCE FUND

In this workers' compensation case, the applicant sought home health care following industrial injuries. The defendant denied authorization via Utilization Review (UR), and the applicant subsequently filed for Independent Medical Review (IMR). The Appeals Board granted the applicant's petition for removal, rescinding the prior order that sent the matter off calendar for IMR. The Board clarified that challenges to the timeliness and procedural validity of UR denials fall under the WCAB's jurisdiction, not IMR. The case is returned to the trial level for an expedited hearing on the validity of the UR decision, with IMR only to proceed if the UR is deemed timely and valid.

Petition for RemovalUtilization ReviewIndependent Medical ReviewWCABWCJOff Calendar OrderHome Health CareDubon v. World RestorationInc.Procedural Defects
References
1
Case No. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. ADJ6933983
Regular
Dec 04, 2015

MARIA CHEVEZ vs. SAP AMERICA, AIG

This case concerns a dispute over further spinal surgery for an applicant with an industrial back injury. The applicant appealed a denial of surgery based on an Independent Medical Review (IMR) decision. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinded the prior finding, and returned the case to the trial level. The WCAB determined that the applicant's appeal of the IMR is permissible regardless of service timeliness and that the Administrative Law Judge must assess if the IMR determination meets statutory standards and constitutes substantial evidence.

Workers Compensation Appeals BoardIndependent Medical ReviewMedical Provider NetworkLabor Code Section 4616.4Petition for ReconsiderationSpinal SurgeryDisc Replacement SurgeryAdministrative Director RulesSubstantial EvidenceTreatment Standards
References
7
Case No. ADJ7332228
Regular
May 04, 2016

Luis Zapanta vs. Pacific Gas & Electric Company

The Workers' Compensation Appeals Board denied Luis Zapanta's petition for reconsideration, upholding the prior ruling that his Independent Medical Review (IMR) was timely. The Board found that the IMR process, including Maximus Federal Services' review, complied with Labor Code section 4610.6(d) and relevant regulations. Applicant's arguments regarding the timeliness of the IMR determination and whether sufficient medical records were reviewed were rejected. The Board affirmed the administrative law judge's decision based on the WCJ's report and additional supporting regulations.

Workers' Compensation Appeals BoardIndependent Medical ReviewMaximus Federal ServicesPetition for ReconsiderationFindings of Fact and OrderLabor CodeCalifornia Code of RegulationsPrimary Treating PhysicianTimelinessSupporting Documentation
References
4
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