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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ADJ8787215
Regular
Jan 10, 2014

FILIBERTO MARTINEZ vs. VORTEX WHIRLPOOL SYSTEMS, INC.; CYPRESS INSURANCE COMPANY, c/o BERKSHIRE HATHAWAY HOMESTATE COMPANIES

The Workers' Compensation Appeals Board denied Filberto Martinez's petition for reconsideration. Martinez sought reimbursement for self-procured medical treatment outside the defendant's Medical Provider Network (MPN), claiming the defendant failed to provide adequate care. The Board found that the defendant provided timely MPN notice and initial medical treatment. Martinez's claim that the treatment was ineffective or a misdiagnosis did not justify self-procurement, as he failed to utilize available internal MPN dispute resolution processes.

Workers' Compensation Appeals BoardPetition for ReconsiderationMedical Provider Network (MPN)Labor Code section 4616.3Self-procured medical treatmentExpedited HearingLabor Code section 4600Medical utilization treatment scheduleIndependent Medical Review (IMR)Findings and Order
References
Case No. ADJ8234651 MF ADJ8234652
Regular
Sep 12, 2014

ZULEMA MIRANDA vs. ARAMARK, permissibly self-insured

The Workers' Compensation Appeals Board granted reconsideration and reversed the Administrative Law Judge's (ALJ) order compelling the employer to authorize out-of-network shoulder surgery. The Board found insufficient evidence that the employer denied, refused, or neglected to provide reasonable treatment for the applicant's left shoulder within its Medical Provider Network (MPN). Therefore, the employer is not liable for the self-procured treatment sought by the applicant outside the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNUtilization ReviewURAgreed Medical EvaluatorAMECumulative InjurySpecific InjuryPetition for Reconsideration
References
Case No. ADJ2757896
Regular
Sep 24, 2018

JOAQUIN GONZALEZ vs. PENHALL INTERNATIONAL CORP, HARTFORD INSURANCE CO.

The Workers' Compensation Appeals Board affirmed a prior order allowing the applicant to seek treatment outside the employer's medical provider network (MPN) for pain management and internal medicine specialists. This decision was based on the employer's failure to schedule timely appointments with specialists within the MPN, as required by regulations. The Board declined to address the employer's request to limit the duration of out-of-network treatment, as this issue was not raised or adjudicated in the initial proceedings. The applicant had sustained a 2005 injury resulting in 100% permanent disability.

Workers' Compensation Appeals BoardMPNMedical Provider NetworkReconsiderationFindings OrderAdministrative Law JudgePermanent DisabilityFuture Medical TreatmentPain ManagementInternal Medicine
References
Case No. ADJ9791003
Regular
Feb 21, 2020

FRANKLIN LOPEZ DE LA CRUZ vs. BARRETT BUSINESS SERVICES, INC.

This case concerns a lien claimant, Optimal Health, seeking reimbursement for medical treatment provided to an applicant injured on July 1, 2014. The applicant's employer accepted a lumbar spine injury but denied claims for thoracic spine, cervical spine, and leg injuries. The initial WCJ disallowed Optimal Health's lien, ruling treatment outside the approved Medical Provider Network (MPN) was improper. The Appeals Board granted reconsideration, finding the applicant may self-procure treatment for denied body parts. The Board remanded the case for further proceedings to determine if the applicant sustained injury to denied body parts, if treatment was reasonable and necessary, and if fees were appropriate.

Medical Provider NetworkMPNdenied body partsself-procured treatmentlien claimantburden of proofindustrial injuryreasonable and necessary treatmentMedical Treatment Utilization ScheduleMTUS
References
Case No. ADJ9438375
Regular
Dec 15, 2016

MARIA FALCON vs. MARRIOTT HOTEL

The Workers' Compensation Appeals Board granted the applicant's Petition for Reconsideration, amending the original decision. The Board found that the defendant's Marriott Hotel failed to provide the applicant with timely medical treatment within their Medical Provider Network (MPN). Applicant attempted to designate five different MPN physicians, but each refused to treat her. This repeated failure constitutes a denial of care, entitling the applicant to seek treatment outside the MPN at the defendant's expense.

Medical Provider NetworkMPN denialOut-of-network treatmentAccess standardsPrimary treating physicianPhysician availabilityLabor Code section 4600Labor Code section 4616Petition for ReconsiderationFindings of Fact and Award
References
Case No. ADJ7431195 ADJ7431206
Regular
Oct 14, 2011

MARICELA SANCHEZ vs. AMERICAN PRINTWORKS / P & Y T-SHIRTS AND SILK SCREENINGS COMPANY, INC., ZENITH INSURANCE COMPANY

This case involves a workers' compensation applicant seeking reconsideration of a prior Appeals Board decision. The Board denied reconsideration, upholding its prior ruling that the defendant provided proper notice of its Medical Provider Network (MPN) and that the applicant was not entitled to payment for self-procured medical treatment outside the MPN. The Board found that the defendant cured any initial notification defects and that the applicant continued self-procuring treatment after being properly notified. Therefore, the defendant is not liable for the applicant's unauthorized medical expenses.

Medical Provider NetworkMPNPetition for ReconsiderationAdministrative Director's RulesNotice of RightsSelf-Procured TreatmentTimely NoticeReasonable Medical TreatmentInadmissible TreatmentAppeals Board en banc
References
Case No. GRO 0032684
Regular
Aug 28, 2007

LUIS CONTRERAS vs. NORTH AMERICAN FIRE HOSE, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board affirmed the WCJ's decision finding an industrial injury and a penalty for unreasonable delay in medical treatment, but denied the applicant's request to go outside the Medical Provider Network (MPN). Although a four-month delay occurred, the Board found that the employer's good-faith efforts to secure treatment within the MPN meant there was no "neglect or refusal" to justify going outside the network. Therefore, the applicant remains within the MPN for treatment.

Workers' Compensation Appeals BoardReconsiderationMedical Provider Network (MPN)Unreasonable DelayLabor Code Section 5814Self-Procured TreatmentNeglect or RefusalKnight v. United Parcel ServiceAndrade v. State Comp. Ins. FundPhysician Choice
References
Case No. ADJ10064259
Regular
Nov 19, 2015

, Applicant, CHARLES WAGNER, vs. , Defendants. BARRETT BUSINESS SERVICES; ACE AMERICAN INS. CO.; CORVEL ADMINSTRATOR

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior order allowing the applicant to treat outside the defendant's Medical Provider Network (MPN). The Board found that while MPN notice requirements are crucial, an employee can only treat outside the network at the employer's expense if a failure to provide notice resulted in a denial of medical care. In this case, the applicant received timely medical treatment, and the defendant presented evidence of providing MPN notices, thus, the applicant was not entitled to self-procured treatment outside the MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)ReconsiderationFindings and OrderAdministrative Law Judge (WCJ)Labor CodeRule 9767.12Medical TreatmentExpedited HearingForklift Operator
References
Case No. ADJ7532885
Regular
Aug 01, 2016

DAVID AREVALO vs. THE MILLARD GROUP, AIG/NATIONAL UNION FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the employer's petition for reconsideration, rescinding prior findings. The Board found the initial decision lacked substantial evidence and failed to address crucial issues like the MPN's validity and the employer's loss of medical control. The case is returned to the trial level for further proceedings to determine these issues and whether the employer refused, delayed, or denied medical treatment. The initial finding of denied treatment was based on insufficient evidence to establish liability for self-procured treatment.

MPNMedical Provider NetworkRefusal of TreatmentDelay of TreatmentDenial of TreatmentLoss of Medical ControlPanel Qualified Medical ExaminerPQMELien ClaimantsPrimary Treating Physician
References
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