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

Case No. ADJ6939280
Regular
Nov 08, 2018

ROBIN GONZALEZ vs. FIRST PRESBYTERIAN CHURCH OF SANTA BARBARA, STATE COMPENSATION INSURANCE FUND

This case concerns applicant Robin Gonzalez's claim for ongoing home health care services following a spinal injury. The employer's insurer denied these services via a timely Utilization Review (UR) based on the Medical Treatment Utilization Schedule (MTUS). The Workers' Compensation Appeals Board (WCAB) affirmed the trial judge's decision, holding that the WCAB lacks jurisdiction to review the UR denial because the process was timely and the dispute over medical necessity must be resolved through the Independent Medical Review (IMR) process, as established in Dubon II. Applicant's treating physician can submit a new request if medically necessary, as the prior UR denial is effective for 12 months.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewMedical Treatment Utilization ScheduleJurisdictionHome Health CarePermanent DisabilityPetition to ReopenFailed Back SyndromeDubon II
References
6
Case No. ADJ2172104 (SAC 0326562)
Regular
Jan 15, 2015

THOMAS MEEKER vs. OREGON PACIFIC BUILDING PRODUCTS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT COMPENSATION INSURANCE COMPANY

This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in *Dubon II*, the Appeals Board reversed this finding. The Board ruled that under *Dubon II*, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.

Utilization ReviewRequest for AuthorizationProvigilDubon IIIndustrial InjuryPermanent DisabilityFuture Medical TreatmentPetition for ReconsiderationAdministrative Law JudgeWorkers' Compensation Appeals Board
References
14
Case No. ADJ11423609
Regular
Sep 12, 2022

DANIEL SERVIN vs. CERRITOS LEXUS, ACE AMERICAN INSURANCE

This case concerns a defendant's petition for reconsideration of an order authorizing left shoulder surgery. The defendant argued a prior utilization review denial should prevent subsequent authorizations, citing Labor Code section 4610(k). However, the applicant's physician resubmitted the request with additional supporting documentation, triggering a new utilization review. This subsequent review certified the surgery as medically necessary, resolving the medical dispute. The Board denied reconsideration, holding that the defendant voluntarily submitted the resubmitted request, making the February 2, 2022 certification final and precluding further utilization review.

Utilization ReviewFindings and OrderPetition for ReconsiderationMedical NecessityReverse Total Shoulder ArthroplastyRequest for AuthorizationNon-certificationCertificationLabor Code Section 4610Resubmission
References
4
Case No. ADJ380850 (SAL 0117839)
Regular
Apr 26, 2011

Sandra Corona vs. LOS APTOS CHRISTIAN FELLOWSHIP CHILDCARE, CHURCH MUTUAL INSURANCE COMPANY

This case involves a defendant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The original decision awarded the applicant further medical treatment, including a cervical radiofrequency ablation. The defendant argued that the applicant failed to follow the proper Labor Code Section 4062 process after their utilization review denied the treatment request. The majority of the WCAB denied reconsideration, holding that an applicant is not strictly required to use Section 4062 to dispute a utilization review denial and may proceed to an expedited hearing, especially when the employer failed to provide adequate information for the review. However, one commissioner dissented, arguing that Section 4062 mandates a dispute resolution process following utilization review.

Workers' Compensation Appeals BoardLabor Code Section 4610Labor Code Section 4062Utilization ReviewReconsiderationFindings and AwardPrimary Treating PhysicianExpedited HearingAgreed Medical ExaminerQualified Medical Examiner
References
2
Case No. MISSING
Regular Panel Decision

Ribya BB. v. Wing

Petitioner initiated a CPLR article 78 proceeding to challenge the denial of her request to expunge her name from the State Central Register of Child Abuse and Maltreatment. An indicated report of child maltreatment was filed after she allegedly left her severely disabled and autistic child unsupervised on three occasions in November 1994. Despite her claim that a cousin was watching the child, an administrative review and subsequent hearing found 'some credible evidence as well as a fair preponderance' of evidence supporting maltreatment, leading to the denial of her expungement request. The Appellate Division confirmed the respondent's determination, citing substantial evidence including admissible double hearsay and inconsistencies in testimony, and dismissed the petition.

Child MaltreatmentExpungementState Central RegisterChild AbuseAdministrative LawJudicial ReviewSubstantial EvidenceHearsay AdmissibilityCredibility AssessmentParental Responsibility
References
11
Case No. ADJ2120886
Regular
Oct 12, 2015

KIMBERLY VAN BUREN vs. PRIMITIVE LOGIC, INC, REPUBLIC INDEMNITY

This case concerns a worker's claim for prescribed medications. The employer argued their utilization review denial was timely, precluding the WCJ's jurisdiction over medical necessity. The Appeals Board affirmed the WCJ's finding that the utilization review denial was untimely due to insufficient evidence of proper and timely communication to the physician. Therefore, the WCJ correctly determined the requested Lidoderm, Capsaicin, and Ketamine creams were reasonable and necessary.

Utilization ReviewTimelinessCommunicationMedical NecessityLabor Code section 4610Administrative Director Rule 9792.9.1Dubon v. World RestorationBodam v. San Bernardino CountyPrimary Treating PhysicianDr. Brendan Morley
References
2
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
5
Case No. ADJ8833224
Regular
Feb 21, 2017

JOHN WEIMER vs. HILLYARD, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board found that an incomplete Request for Authorization (RFA) with an incorrect claim number was submitted on September 19, 2016. Despite the error, the RFA successfully identified the employee and triggered the defendant's duty to conduct utilization review on that date. Consequently, the defendant's utilization review denial on September 29, 2016, was deemed untimely, invalidating the denial. The case was returned for further proceedings to determine the necessity of the requested medical treatment.

DWC RFAUtilization ReviewTimelinessClaim NumberIncomplete RequestMedical TreatmentReconsiderationAdministrative Director RuleTreating PhysicianClaims Adjuster
References
1
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
6
Case No. ADJ 1390531 (LBO 0388008)
Regular
Apr 11, 2018

SARITA JANE BISSETT-GARCIA vs. PEACE AND JOY CENTER, VIRGINIA SURETY COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding a prior finding that the defendant's utilization review (UR) process was untimely. The WCAB found that the UR denial for home care assistance was issued within the statutory five business days, despite an alleged deficiency in the initial denial letter. Consequently, the WCAB determined it lacked jurisdiction to review the medical necessity of the requested treatment, as only timely UR decisions are subject to WCAB review.

Workers' Compensation Appeals Boardutilization reviewadministrative law judgereconsiderationcompromise and release agreementmedical treatmentLabor Code section 4610Administrative Director Rule 9792.9.1primary treating physicianindependent medical review
References
2
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