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

Case No. ADJ1310206 (LAO 0876076) ADJ7403858
Regular
Sep 30, 2011

Norma Flores vs. HMS HOST, ACE USA INSURANCE

The Workers' Compensation Appeals Board denied Norma Flores' petition for reconsideration, affirming the Workers' Compensation Judge's (WCJ) prior decision. The Board incorporated the WCJ's report, which found that Flores waived her argument regarding the 90-day denial period under Labor Code section 5402 by not raising it at trial. Furthermore, the WCJ's credibility findings regarding the applicant's medical history and subjective complaints were given great weight, supporting the denial of further benefits. The WCJ's reliance on Dr. Timothy Ross's reports over Dr. Philip Sobel's was deemed substantial evidence, leading to the conclusion of no new or further disability.

Workers' Compensation Appeals BoardPetition for ReconsiderationWCJ ReportGarza v. Workers' Comp. Appeals Bd.Labor Code section 5402continuous trauma claimsubstantial evidencepanel qualified medical examinernew and further disabilitytemporary total disability
References
1
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. ADJ11170562
Regular
Dec 02, 2019

NASIR KHAN vs. STAR STAFFING, ZURICH NORTH AMERICA, GALLAGHER BASSETT SERVICES, INC.

Defendant sought removal of a WCJ's order finding their utilization review denial of applicant's medical treatment request untimely. The WCJ determined the denial was late due to the 72-hour window for expedited requests, as the applicant's physician requested "urgent surgery." The Appeals Board denied the petition for removal, finding the defendant failed to show irreparable harm and that reconsideration would be an inadequate remedy. The Board upheld the WCJ's finding of untimely UR, allowing the Board to determine medical necessity.

Petition for RemovalUtilization ReviewExpedited Request for AuthorizationMedical Treatment Utilization StandardsTimelinessAdministrative Director RuleThreshold IssueInterlocutory IssueMedical NecessityPrimary Treating Physician
References
6
Case No. ADJ1 0277951
Regular
Jul 17, 2017

DANNY HILL vs. STATE OF CALIFORNIA DEPARTMENT OF TRANSPORTATION, legally uninsured and adjusted by STATE COMPENSATION INSURANCE FUND

The defendant, Department of Transportation, sought to compel the applicant, Danny Hill, to disclose all prior permanent disabilities and physical impairments under Labor Code section 4663(d). The WCJ initially denied the defendant's petition, finding no good cause. The Appeals Board granted the defendant's Petition for Removal, rescinded the WCJ's denial, and returned the matter for further proceedings. The Board found the WCJ's denial unsupported, as Labor Code section 4663(d) unequivocally requires such disclosure upon request.

Petition for RemovalPetition to Compel DisclosureLabor Code section 4663(d)permanent disabilitiesphysical impairmentsWCJ denialAppeals Boardtrial levelmedical treatmentapplicant disclosure
References
2
Case No. ADJ11292320
Regular
Mar 03, 2020

MELINDA PRISKIN vs. BANK OF AMERICA, XL INSURANCE

The Workers' Compensation Appeals Board granted the defendant's Petition for Removal, rescinding the WCJ's prior order. The Board found the WCJ erred by proceeding with an expedited hearing on issues that were not ripe for such a hearing, specifically the denial of injury AOE/COE and the presumption of compensability under Labor Code Section 5402. The defendant was denied due process as it did not have an opportunity to present evidence regarding the timeliness of its denial or the personnel defense. The matter was returned to the WCJ for further proceedings, including a proper hearing to develop the evidentiary record.

Petition for RemovalExpedited HearingLabor Code Section 5402Late DenialInjury AOE/COEDue ProcessDeclaration of Readiness to ProceedWCJWorkers' Compensation Appeals BoardTemporary Disability
References
7
Case No. ADJ6444600
Regular
Jan 22, 2020

PAUL AGUILAR vs. CITY OF LOS ANGELES

This case involved a dispute over the timeliness of a utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, finding the original WCJ erred by concluding the UR denial was untimely solely due to lack of telephone/fax communication. While the WCAB agreed the UR denial was untimely because it wasn't communicated to the physician as required by law, it found the record incomplete regarding the medical necessity of the treatment. Therefore, the WCAB rescinded the order authorizing treatment and returned the matter to the WCJ for further proceedings to determine medical necessity.

Utilization ReviewRequest for AuthorizationTimelinessCommunicationProspective TreatmentLabor Code Section 4610Administrative Director RuleBodam v. San Bernardino CountyMedical NecessitySubstantial Evidence
References
9
Case No. ADJ6950787
Regular
Jun 22, 2012

JOSE BARRIENTOS vs. MARK GREENBERG, ALLSTATE INSURANCE COMPANY, SEDGWICK CMS

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The defendant argued the administrative law judge (WCJ) abused discretion by finding the applicant credible, specifically regarding the duration of employment to exclude him from employee status under Labor Code §3352(h). The WCJ adopted the report recommending denial, emphasizing applicant's credible testimony regarding hours worked and pay, and finding the defendant's testimony less reliable due to a lack of direct knowledge. The Board extended great weight to the WCJ's credibility findings, affirming the denial of reconsideration.

Workers' Compensation Appeals BoardPetition for ReconsiderationWCJcredibility findingLabor Code §3352(h)employee definitionconflicting testimonyobservational demeanorunreliable testimonyunrebutted testimony
References
1
Case No. ADJ3033562 (GRO 0024532)
Regular
Jun 27, 2017

Thomas Cullen vs. Atascadero Ford, Inc., State Compensation Insurance Fund

This case concerns the denial of ongoing aqua therapy for applicant Thomas Cullen, who suffered a 1998 work injury resulting in 100% permanent disability and future medical care. The defendant employer and insurer argued their Utilization Review (UR) denial was timely and binding, and that the WCJ misapplied precedent. The Appeals Board affirmed the WCJ's decision to award the aqua therapy, finding the defendant's UR decision invalid due to procedural issues. As a result, the WCJ could properly determine the treatment was reasonable and medically supported by substantial evidence, especially since the applicant's condition worsened when therapy was withdrawn.

Workers' Compensation Appeals BoardReconsiderationAdministrative Law JudgeLabor Code section 5814Patterson v. The Oaks FarmRequest For AuthorizationUtilization Reviewinvalid UR decisionreasonable medical treatmentsubstantial evidence
References
3
Case No. ADJ12194461
Regular
Dec 10, 2020

Antonio Lemus vs. STEVE P. RADOS, INC., STARR INDEMNITY & LIABILITY COMPANY

This case concerns applicant Antonio Lemus's entitlement to home health care following an admitted industrial head injury. Defendant sought reconsideration of a WCJ's award enforcing a Utilization Review (UR) determination that modified but approved home health aide services. The defendant argued the WCJ lacked jurisdiction to enforce the UR determination due to a second, later UR denial of the same request, which they claimed was timely. The Appeals Board affirmed the WCJ's decision, finding jurisdiction to enforce the initial UR approval and deeming the subsequent denial an improper "self-granted appeal." The Board concluded the applicant was entitled to the treatment approved by the first UR determination.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationIndependent Medical ReviewFindings Orders and AwardPetition for ReconsiderationNurse Case ManagerTraumatic Brain InjuryHome Health AideMedical Treatment
References
2
Case No. ADJ8488097
Regular
Feb 15, 2019

JOHN ROBERTSON vs. BOSCO OIL, WAUSAU UNDERWRITERS INSURANCE, LIBERTY MUTUAL

This case involves John Robertson's workers' compensation claim against Bosco Oil, adjusted by Liberty Mutual. The Workers' Compensation Appeals Board denied Robertson's Petition for Reconsideration. This denial is based on the WCJ's report, which the Board fully adopts and incorporates. The specific reasons for the denial are detailed within the WCJ's report, which was not provided here.

Petition for ReconsiderationDenying PetitionWorkers' Compensation Appeals BoardWCJ's reportApplicantDefendantsBosco OilWausau Underwriters InsuranceLiberty MutualADJ8488097
References
0
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