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

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. 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. ADJ4133886 (AHM 0150741)
Regular
Jan 18, 2011

HUGO ABADIA vs. QUICKSILVER, INC., ACE USA

This case involves a dispute over an applicant's entitlement to spinal surgery following an admitted industrial injury. The defendant seeks reconsideration of a decision awarding surgery, arguing the utilization review denial was timely and the applicant waived timeliness objections by agreeing to an Agreed Medical Examiner (AME) process. The Appeals Board granted reconsideration, finding the applicant waived their right to object to the timeliness of the utilization review by participating in the AME process. Consequently, the Board rescinded the award and remanded the case for further proceedings to address the medical necessity of the surgery, including the AME's reports.

Workers' Compensation Appeals BoardUtilization ReviewAgreed Medical ExaminerReconsiderationExpedited HearingFindings and AwardSpinal SurgeryLow Back InjuryWaiverTimeliness
References
2
Case No. MISSING
Regular Panel Decision
Oct 12, 1990

North Fork Environmental Council, Inc. v. Janoski

This case involves a CPLR article 78 proceeding to challenge the Town Board of Riverhead's determination to grant a special permit for a condominium development to Mill Pound Commons. The petitioner argued that the environmental impact statements were defective because the Town Board failed to consider the cumulative environmental effects of the project with other proposed projects in the Saw Mill Creek basin and did not consider archaeological impacts. The Supreme Court, Suffolk County, affirmed the Town Board's decision, finding that the projects were not "reasonably related" for a mandatory cumulative impact review and that archaeological impacts were not raised or supported during the review process. The court emphasized that a Critical Environmental Area designation alone does not mandate a cohesive framework for cumulative impact review and that new issues cannot be raised after the completion of the Environmental Impact Statement process.

Environmental Impact StatementSEQRACumulative Impact ReviewSpecial PermitCondominium UseTown Board DeterminationCritical Environmental AreaArchaeological ResourcesPublic CommentCPLR Article 78
References
4
Case No. ADJ2798585 (MON 0241152) MF ADJ2723676 (MON 0241153)
Regular
Aug 21, 2018

Maxine Wiggs vs. Allied Signal Aerospace, St. Paul Travelers Insurance

This case involves applicant Maxine Wiggs' claim for industrial injuries sustained in 1997 and 1997-1998, leading to a need for medical treatment. The Workers' Compensation Appeals Board (WCAB) reviewed a prior decision ordering the defendant to have a Nurse Case Manager assess the applicant's need for heavy home health care. The WCAB affirmed the WCJ's decision, finding jurisdiction to enforce a prior stipulation regarding the evaluation of home health care needs, even with the existence of Utilization Review (UR) and Independent Medical Review (IMR) processes. However, one commissioner dissented, arguing that the matter should be resolved through UR and IMR, asserting the WCJ lacked authority to circumvent these statutory processes.

ADJ2798585ADJ2723676Nurse Case ManagerIrene MeffordHome health careUtilization ReviewIndependent Medical ReviewLabor Code Section 4610Labor Code Section 4610.5Labor Code Section 5900
References
13
Case No. MISSING
Regular Panel Decision

In re Paragon Process Service, Inc.

Paragon Process Service, Inc. appealed a decision by the Unemployment Insurance Appeal Board, which held the company responsible for unemployment insurance contributions for its process servers from 1978 to 1980. Paragon contended that these process servers were independent contractors, not employees, over whom it exercised no control beyond legal requirements. The court, referencing precedents like *Matter of 12 Cornelia St. (Ross)*, determined that the Board lacked a rational basis for classifying the process servers as employees. Consequently, the court reversed the Board's decision. The matter was then remitted to the Unemployment Insurance Appeal Board for further proceedings consistent with this new finding.

Unemployment insuranceIndependent contractorProcess serversEmployer liabilityEmployee classificationAppellate reviewAdministrative decisionRational basis reviewLabor lawNew York law
References
2
Case No. MISSING
Regular Panel Decision

Steuben Foods, Inc. v. GEA Process Engineering, Inc.

Plaintiff Steuben Foods, Inc. initiated a patent infringement lawsuit against Defendants GEA Process Engineering and GEA Procomac S.p.A., alleging infringement of United States Patent No. 6,209,591. The case involved motions for summary judgment filed by the Defendants, which were subject to reports and recommendations by a Magistrate Judge. Following Plaintiff's objections to the Magistrate Judge's second Report and Recommendation, the District Court reviewed the matter de novo. The Court ultimately denied Plaintiff's objections and adopted the Magistrate Judge's recommendation, granting Defendants' amended motion for summary judgment. The decision hinged on the proper construction of the patent claim term "into," which the Court found to imply the possibility of contact with the contents of a region, a condition not met by the accused product.

Patent InfringementSummary JudgmentClaim ConstructionFederal Rules of Civil ProcedureMagistrate JudgeReport and RecommendationObjectionsSterile RegionsValve Activation MechanismAseptic Processing
References
12
Case No. RDG 0115958
En Banc
Nov 16, 2004

Brice Sandhagen vs. Cox & Cox Construction, Inc.; State Compensation Insurance Fund

The Appeals Board held that utilization review time deadlines under Labor Code section 4610(g)(1) are mandatory. A defendant's failure to comply precludes the use of the utilization review process, renders the resulting report inadmissible, and requires the defendant, as the objecting party, to follow the dispute resolution procedures of section 4062(a).

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610(g)(1)Mandatory DeadlinesAdmissibility of EvidenceACOEM GuidelinesTreating PhysicianMedical Treatment RecommendationAgreed Medical Evaluator (AME)Qualified Medical Evaluator (QME)
References
23
Case No. ADJ593260 (SAC 033875)
Regular
May 12, 2009

LAURA WEST-MCBRIDE vs. AMERICAN RESTAURANT GROUP AND CIGA, CALIFORNIA COMPENSATION INSURANCE COMPANY IN LIQUIDATION, BROADSPIRE

This case concerns an employer's liability for chiropractic treatment recommended by applicant's physician. The defendant sought reconsideration of a finding that they were liable for the requested treatment, arguing it contradicted medical guidelines and that the request was improperly submitted for utilization review. The Board granted reconsideration, amending the decision to limit liability to treatment rendered between April 15, 2008, and May 7, 2008. The issue of liability for subsequent treatment was deferred pending completion of the utilization review dispute resolution process.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and Orderindustrial injurychiropractic careACOEM Guidelinesutilization reviewLabor Code Section 4610medical necessityAdministrative Director Rule 9792.9(j)
References
2
Case No. ADJ2086501 (SFO 0318776)
Regular
Nov 07, 2014

KIM McCOOL (NELSON) vs. MONTEREY BAY MEDICAR, ARROWOOD INDEMNITY COMPANY

This case involves a dispute over the authorization of pain medications for an applicant with a 1983 back injury. The employer initially denied medications based on utilization review but later approved them. The administrative law judge still awarded the medications, but the Appeals Board granted reconsideration. The Board rescinded the award, finding no actual dispute existed at the hearing and that the prior denial, though flawed, did not warrant the judge's ruling. The Board also noted concerns about the utilization review process potentially violating regulations.

Utilization ReviewPetition for ReconsiderationFindings and AwardOxyContinNorcoLyricaAmbulance DriverPermanent DisabilityExpedited HearingMedical Treatment
References
2
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