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

Case No. ADJ9731055
Regular
Dec 07, 2018

JORGE HERNANDEZ vs. HEALD COLLEGE, ZURICH NORTH AMERICA

The Workers' Compensation Appeals Board dismissed Jorge Hernandez's petition for reconsideration because it was unverified, a mandatory requirement under Labor Code section 5902. The Board noted that the defect was pointed out in the WCJ's report and applicant's answer, yet the petitioner failed to cure the defect or provide a compelling explanation within a reasonable time. Therefore, the petition was dismissed on procedural grounds. Had it not been dismissed, the Board indicated it would have denied the petition on its merits, partly due to the defendants' failure to prove timely utilization review (UR) compliance.

WCABPetition for ReconsiderationUnverified PetitionLabor Code 5902Verification DefectLucena v. Diablo Auto BodyUtilization Review (UR)Timeliness of UR DecisionDubon v. World RestorationInc.
References
Case No. ADJ9070770
Regular
Jun 10, 2014

OSCAR GARCIA-PICEN vs. TIGHT QUARTERS, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) rescinded a prior ruling ordering viscosupplementation injections for an applicant's knee injury. The WCAB found the prior ruling, which deemed the defendant's utilization review (UR) denial defective due to a missing signature, to be based on an incorrect premise as the UR physician did sign the report. However, the WCAB noted the UR physician may not have been aware of the applicant's second surgery, potentially rendering the UR defective for other reasons. The case was returned to the trial level for further consideration, with a dissenting opinion arguing the UR was demonstrably defective for omitting key medical history and the treatment should have been affirmed.

Workers' Compensation Appeals BoardOscar Garcia-PicenTight QuartersInc.California Insurance CompanyADJ9070770Opinion and Decision After ReconsiderationViscosupplementation injectionsUtilization Review (UR) denialDefective UR
References
Case No. ADJ8039057
Regular
Jan 07, 2014

LAURIE CARRICO vs. LAW OFFICES OF STEPHEN BELGUM, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior finding that the defendant's utilization review (UR) was defective regarding the applicant's shoulder surgery. The WCAB clarified its jurisdiction, stating it can only determine UR timeliness. All other disputes regarding the UR decision, including its compliance with Labor Code section 4610, must be resolved through Independent Medical Review (IMR). Therefore, the case was returned to the trial level to complete the IMR process.

Workers' Compensation Appeals BoardLaurie CarricoLaw Offices of Stephen BelgumState Compensation Insurance FundADJ8039057San BernardinoOpinion and Decision After ReconsiderationFindings and Awardindustrial injuryshoulders
References
Case No. ADJ9712319
Regular
Jun 20, 2025

ELEANOR DIAZ NEVAREZ vs. ELK GROVE UNIFIED SCHOOL DISTRICT, SCHOOLS INSURANCE AUTHORITY

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by defendant Elk Grove Unified School District. The Board affirmed the WCJ's decision that the utilization review (UR) was untimely and procedurally defective, specifically regarding a Request for Authorization (RFA) for an H-Wave device. The defendant had argued the RFA was incomplete, but the Board found it procedurally complete, thus triggering UR obligations. The Board concluded that the defendant's failure to issue a timely conditional denial, as required by regulations, rendered the UR invalid and untimely. Additionally, the Board confirmed its decision was issued in compliance with the 60-day timeframe stipulated by Labor Code section 5909.

WCABPetition for ReconsiderationLabor Code section 5909TransmissionElectronic Adjudication Management SystemEAMSReport and RecommendationUtilization ReviewURRequest for Authorization
References
Case No. ADJ9349861
Regular
Aug 08, 2014

Ernest Millette vs. 81 Grand Holdings, Inc., dba California Rehabilitation, Illinois Midwest Insurance Agency, LLC on behalf of PROCENTURY INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, upholding the prior award of medical care. The Board adopted the judge's report which found the defendant's arguments regarding causation and utilization review (UR) to be unsupported by evidence. The judge admonished defendant's counsel for misstating the record and noted that the defendant failed to provide a clear basis for disputing causation or denying injury benefits within the required timeframes.

Workers' Compensation Appeals BoardPetition for ReconsiderationWCJ reportSection 9792.9.1(b)(1)(C)Rule 9792.9.1(b)(1)(D)admonish counselmisstating evidencecausationspecific injuryoccupational therapist
References
Case No. ADJ4588032 (VNO 0509614)
Regular
May 13, 2009

PEGGY SPARGO vs. CITY OF BALDWIN PARK

This case involves a lien claimant, RS Medical, seeking payment for durable medical equipment provided to an applicant for an admitted industrial injury. The defendant, City of Baldwin Park, denied authorization for the treatment through its utilization review (UR) process. The Workers' Compensation Appeals Board (WCAB) denied reconsideration, upholding the trial judge's decision. The WCAB found that the defendant's UR denials were timely and unchallenged by the applicant, and thus RS Medical failed to prove the necessity of the treatment or sustain its burden of proof for payment. Therefore, the employer is not liable for the unauthorized medical treatment.

Workers' Compensation Appeals BoardCity of Baldwin ParkRS Medicallien claimreconsiderationFindings and Orderworkers' compensation judgeWCJindustrial injuryupper extremities
References
Case No. ADJ3135829 (AHM 0099139)
Regular
Jul 28, 2014

CAROLYN BERTRAND vs. COUNTY OF ORANGE, YORK

This case concerns a dispute over medical treatment disputes between an applicant and the County of Orange. The parties had previously stipulated to have the Agreed Medical Examiner (AME), Dr. Wilson, resolve future treatment disputes, potentially bypassing the statutory Utilization Review (UR) and Independent Medical Review (IMR) processes. The Workers' Compensation Appeals Board (WCAB) dismissed the employer's petition for reconsideration as the prior order was procedural, but granted removal. As a decision after removal, the WCAB clarified that while the stipulation to use the AME is valid and can supersede IMR, treatment requests must first go through UR, and only subsequent disputes are referred to the AME.

StipulationAgreed Medical ExaminerAMEUtilization ReviewURIndependent Medical ReviewIMRRemovalPetition for ReconsiderationLabor Code section 4610
References
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
Case No. ADJ8454101
Regular
Dec 18, 2014

Joshua Desmarias vs. California Highway Patrol

The Appeals Board rescinded the original WCJ's decision, finding the applicant's appeal of the UR denial for spinal surgery is denied. The Board clarified that a procedural defect in a UR report, such as an illegible signature, does not invalidate the UR determination unless the UR itself was untimely. Since the parties stipulated the UR was timely, the Board lacked jurisdiction to determine the medical necessity of the surgery. Therefore, the IMR decision upholding the UR denial stands, and the applicant's request for surgery is denied.

Workers' Compensation Appeals BoardCalifornia Highway Patrollegally uninsuredState Compensation Insurance FundFindings of Fact and Orderindustrial injuryutilization reviewUR denialspinal surgeryorthopedic surgeon
References
Case No. ADJ9917212
Regular
Mar 17, 2016

MICHAEL GREEN vs. ELLE PLACEMENT dba GOLDEN GATE STAFFING, LUMBERMEN'S UNDERWRITING ALLIANCE

This case concerns the timeliness of a defendant's utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) rescinded the initial decision awarding treatment, finding the defendant's UR denial was timely made and served within the five-business-day window. The key issue was whether a UR denial sent via facsimile after 5:30 p.m. on the fifth business day was valid. The Board concluded the UR decision was timely made and communicated within 24 hours of its making, rendering it valid and requiring disputes to go through the Independent Medical Review (IMR) process.

Utilization ReviewRequest for AuthorizationIndependent Medical ReviewWCJBusiness DayFacsimile Date StampAdministrative DirectorMedical TreatmentSpinal SurgeryArthroplasty
References
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