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Case Law Database

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

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
Case No. ADJ422252 (SBR 0302367)
Regular
Apr 12, 2017

ELAINE HACKER vs. COUNTY OF SAN BERNARDINO-PUBLIC HEALTH DEPARTMENT

The Appeals Board granted the defendant's petition for removal, reversing the WCJ's decision that rescinded an Independent Medical Review (IMR) determination. The Appeals Board found that a family practice physician reviewing treatment for chronic pain was not plainly erroneous, nor did it exceed the Administrative Director's powers. Consequently, the July 8, 2016 IMR determination is now considered final and binding. Additionally, the WCJ's proposed monetary sanctions against defense counsel were rescinded due to the lack of a prior ruling on the defense's procedural arguments.

Workers' Compensation Appeals BoardPetition for RemovalFindings and OrderLabor Code 4610.6(h)Independent Medical ReviewAdministrative DirectorUtilization ReviewPlainly Erroneous FindingChronic Pain SpecialistNotice of Intention to Impose Monetary Sanctions
References
Case No. ADJ21 45168 (GOL 0096589)
Regular
Sep 20, 2016

THOMAS HOGENSON vs. VOLKSWAGEN OF AMERICA, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

This case concerns whether medical treatment proposed by an injured worker's physician, chosen from the employer's Medical Provider Network (MPN), is subject to Utilization Review (UR) and Independent Medical Review (IMR). The Workers' Compensation Appeals Board (WCAB) rescinded the administrative law judge's award of treatment, holding that MPN treatment is indeed subject to UR and IMR. The WCAB clarified that statutory provisions for UR and IMR apply to all medical treatment disputes, regardless of whether the physician is within an MPN. The matter was returned to the trial level for further proceedings consistent with this decision.

Workers' Compensation Appeals BoardThomas HogensonVolkswagen of AmericaInsurance Company of the State of PennsylvaniaExpedited Findings Of Fact And AwardUtilization ReviewMedical Provider NetworkIndependent Medical ReviewMedical TreatmentLabor Code
References
Case No. ADJ2117331 (OAK 0261803)
Regular
May 31, 2017

Janice Payne vs. Federal Express, BROADSPIRE

This case involves Janice Payne seeking reconsideration of a Workers' Compensation Appeals Board (WCAB) decision denying her weight loss program extension. The WCJ initially ruled he lacked jurisdiction due to prior Utilization Review (UR) and Independent Medical Review (IMR) denials, which were not appealed. However, the applicant argued a 2003 Compromise and Release agreement designated Dr. Mandel as the ultimate medical arbiter for treatment disputes, superseding UR/IMR. The WCAB granted reconsideration, finding the contractual agreement to use Dr. Mandel remains enforceable despite subsequent UR/IMR legislation. The case is remanded to the trial level to consider Dr. Mandel's opinions on the weight loss program's medical necessity.

Compromise and ReleaseMedical ArbiterUtilization ReviewIndependent Medical ReviewWeight Loss ProgramContractual AgreementJurisdictionSubstantial JusticeStipulationMedical Treatment Dispute
References
Case No. ADJ8338903
Regular
Sep 19, 2016

IRMA DE LEON vs. SAFEWAY, INC.

This case concerns whether medical treatment provided within a Medical Provider Network (MPN) is subject to Utilization Review (UR) and Independent Medical Review (IMR). The Appeals Board reversed the WCJ, holding that MPN treatment is indeed subject to UR/IMR. Delays in IMR determinations do not invalidate them. The March 21, 2014 IMR determination was deemed binding as no grounds for appeal were established.

MPNUtilization ReviewIndependent Medical ReviewMedical Treatment Utilization ScheduleLabor Code section 4610Medical Provider NetworkRequest for AuthorizationDirectory vs. Mandatory Time PeriodMargarisSB 863
References
Case No. ADJ339088 (SDO 0304788)
Regular
Aug 30, 2016

Gregory Parrent vs. SBC-PACIFIC BELL TELEPHONE COMPANY

This case clarifies the utilization review (UR) and independent medical review (IMR) process for medical treatment recommendations within a Medical Provider Network (MPN). The Appeals Board affirmed that even when a physician is part of the defendant's MPN, their treatment recommendations are subject to UR by the employer if disputed. If UR denies or modifies the recommendation, the dispute must then proceed to IMR, not the Appeals Board. The applicant's contention that MPN physicians' recommendations are exempt from UR was rejected, emphasizing a uniform standard of care and review for all medical treatment.

Workers' Compensation Appeals BoardSBC-Pacific Bell Telephone CompanySedgwick Claims Management ServicesPetition for ReconsiderationMedical Provider Network (MPN)Independent Medical Review (IMR)Utilization Review (UR)Labor Code section 4600primary treating physicianRequest for Authorization (RFA)
References
Case No. ADJ6907549, ADJ9156151
Regular
May 28, 2015

Leticia Avila vs. University of California Irvine Medical Center, SEDGWICK CMS

This case clarifies that an employee must *receive* their Independent Medical Review (IMR) application within 30 days of the Utilization Review (UR) denial, plus a 5-day extension if the denial was served by mail. The applicant's IMR application was deemed untimely because it was received by the Administrative Director one day after the extended deadline. This decision affirms the WCJ's finding that the applicant's IMR application was not filed within the mandatory statutory timeframe. The concurring opinion stresses the importance of timely adherence to all timeframes within the UR/IMR process.

Workers' Compensation Appeals BoardIndependent Medical ReviewUtilization ReviewLabor Code section 4610.5(h)(1)Administrative Director's Rule 9792.10.1(b)(2)Code of Civil Procedure section 1013(a)timely filingsubmission datereceipt dateservice by mail
References
Case No. ADJ4092389 (SBR 0291114), ADJ4203796 (SBR 0291115), ADJ3646941 (SBR 0309645)
Regular
Jul 20, 2018

Gregory Long vs. RALPHS GROCERY COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board (WCAB) denied reconsideration of a Findings and Order that found the defendant complied with a prior Independent Medical Review (IMR) decision. The WCAB affirmed the administrative law judge's ruling that each prescription for applicant Gregory Long's opioid pain medication requires separate Utilization Review (UR) and potential IMR, despite a previous IMR approval. The Board also noted its lack of jurisdiction to hear constitutional challenges to the UR/IMR process. Applicant's claims of unequal protection and fraud were rejected, and the WCAB found no impairment to his access to medical treatment.

Workers' Compensation Appeals BoardGregory LongRalphs Grocery CompanySedgwick Claims Management ServicesPetition for ReconsiderationFindings and OrderExpedited HearingWCJIMR determinationUtilization Review (UR)
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. 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
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