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

Case No. ADJ9145724
Regular
Jun 01, 2015

ARZAGA, JOSE vs. CROWN AUTOMOTIVE, INC., AMTRUST NORTH AMERICA

This case involves an applicant seeking to select a pain management specialist outside his employer's Medical Provider Network (MPN). The applicant argued the MPN failed to provide a qualifying specialist within the required 15-mile/30-minute access standard for a primary treating physician. The Board denied the employer's petition for reconsideration, affirming the applicant's right to choose an out-of-network physician and reimbursement for investigative costs. The majority reasoned that the MPN must meet the closer access standard for a primary treating physician, even if that physician is a specialist. A dissenting opinion argued that a specialist, when chosen as a primary treating physician, should fall under the 30-mile/60-minute access standard for specialists.

Medical Provider NetworkMPNprimary treating physicianpain management specialistaccess standardAdministrative Director's Rule 9767.5investigative costsLabor Code section 5703Lescallett v. Wal-MartMartinez v. New French Bakery
References
2
Case No. ADJ6729105
Regular
Sep 16, 2009

, ## Applicant, vs. , ## Defendant(s).

The Workers' Compensation Appeals Board denied reconsideration of a ruling that utilization review for the applicant's shoulder surgery was timely. The applicant argued she did not receive the denial letter within the required timeframe, but the Board found that the denial was properly sent to the treating physician and carbon-copied to the applicant within the statutory period. The Board clarified that WCAB Rule 10505(d) regarding official address records did not apply at the time of the denial because no claim application was yet filed. Therefore, the carrier's obligation was to communicate the denial in writing within the specified time, which they did.

Workers' Compensation Appeals BoardCadbury SchweppesGallagher Bassett ServicesUtilization ReviewPetition for ReconsiderationApplication for Adjudication of ClaimWCAB Rule 10505(d)Labor Code Section 4610ArthroscopyBiceps Tenodesis
References
0
Case No. ADJ9048259
Regular
Dec 30, 2015

Antonio Avila vs. Barrett Business Services, Inc., Corvel Insurance Company

Here's a summary of the case in four sentences for a lawyer: The Workers' Compensation Appeals Board denied reconsideration, upholding the judge's decision that the applicant must treat within the employer's Medical Provider Network (MPN). The Board found that while there were some informational deficiencies, they did not amount to a denial of medical treatment that would justify treating outside the MPN. Crucially, the applicant admitted he liked his MPN physician and only sought to change doctors based on his attorney's recommendation. Evidence showed the employer promptly provided medical treatment and confirmed the applicant's treating physician was within their MPN.

Workers' Compensation Appeals BoardPetition for ReconsiderationMPNMedical Provider NetworkWCJHealth First Medical GroupDr. Eliasattorney's recommendationBBSI MPNCorvel Insurance Company
References
1
Case No. ADJ7925931, ADJ7925917
Regular
Sep 27, 2017

LUISA SEQUEIRA vs. RANDSTAD PLACEMENT PROS, ACE AMERICAN

This case involved an applicant seeking reconsideration of a workers' compensation award, arguing that the declaration of readiness to proceed was defective due to a lack of a primary treating physician's report on permanent disability. The Appeals Board affirmed the original award, finding that Labor Code section 4061(i) does not require all treating physicians to find maximum medical improvement before proceeding to trial. The Board reasoned that the applicant's Panel Qualified Medical Evaluator (PQME) provided substantial medical evidence sufficient to support the permanent disability award, even though primary treating physicians had not yet found MMI. Therefore, the WCJ correctly relied on the PQME's report.

Declaration of readinessPermanent disabilityPrimary treating physicianQualified Medical EvaluatorMaximum medical improvementLabor Code section 4061(i)Substantial medical evidenceFindings Award and OrderReconsiderationIndustrial injury
References
3
Case No. ADJ9687796
Regular
Mar 23, 2015

MOHAMMAD RAFIQ vs. VILLAGE NURSERIES, APPLIED RISK

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration. The applicant sought treatment outside the defendant's Medical Provider Network (MPN), arguing the MPN lacked toxicologists. The judge found the applicant was not entitled to out-of-MPN treatment as they were not treating with a toxicologist and the MPN had sufficient internal medicine physicians. The applicant also failed to prove medical necessity for a toxicologist through treating physician reports.

Workers' Compensation Appeals BoardPetition for ReconsiderationDeniedMPNLabor Code §4616(a)Cal. Code of Reg. §9767.5Medical TreatmentSelf-Procured Medical TreatmentToxicologistInternal Medicine
References
0
Case No. ADJ7267845
Regular
Feb 21, 2012

JOSE ACEVEDO vs. TREND PERSONNEL, CHARTIS INSURANCE, GALLAGHER BASSETT SERVICES

This case concerns whether medical liens for treatment rendered after December 18, 2008, are valid. The primary treating physician, Dr. Hoegel, released the applicant from care on that date, and the applicant failed to object to this determination under Labor Code sections 4061 and 4062. Therefore, the applicant could not designate a new primary treating physician and any subsequent treatment liens are barred. The Appeals Board granted reconsideration to clarify that the applicant's failure to follow statutory objection procedures invalidates post-release medical liens.

Workers' Compensation Appeals BoardReconsiderationDecision After ReconsiderationFindings of Facts Re: LiensTenet/Centinela Hospital Medical Center v. Workers' Comp. Appeals Bd. (Rushing)Primary Physician's Permanent and Stationary ReportCompromise and ReleaseLien ClaimantsLabor Code section 4061(b)Labor Code section 4062(a)
References
1
Case No. ADJ1412190 (VEN 0122058)
Regular
May 29, 2018

CHRIS EMERSON vs. CHATSWORTH TRANSMISSION, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration, rescinding the trial judge's finding that the applicant's condition was permanent and stationary as of July 10, 2017. This decision was based on the applicant's argument that the Qualified Medical Evaluator's (QME) report was not substantial evidence because it did not consider more recent reports from the applicant's treating physician. Subsequent treatment recommendations by the treating physician, including injections and potential surgery, indicated the applicant's condition may not be stable. The case is remanded for further proceedings to develop the record, specifically by having the QME review the updated medical reports.

Workers' Compensation Appeals BoardPetition for ReconsiderationTemporary DisabilityPermanent and Stationary DateQualified Medical Evaluator (QME)Primary Treating Physician (PTP)Substantial EvidenceMedical OpinionLumbar LaminectomyEpidural Injections
References
0
Case No. ADJ9798663
Regular
Sep 02, 2015

ALEJANDRO SAUCEDO SAHAGUN vs. TXC LOUTER'S DAIRY, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the applicant's petition for reconsideration, rescinding the previous award. The applicant sought to change treating physicians outside the defendant's Medical Provider Network (MPN), arguing the MPN failed to meet access standards for primary treating physicians within 15 miles or 30 minutes of his home or work. The Board found the trial judge applied an incorrect, less stringent access standard, and remanded the case for application of the proper standard. The applicant's injury and initial treatment within the MPN were admitted.

Workers' Compensation Appeals BoardMedical Provider NetworkMPN access standardsAdministrative Director's Rule 9767.5rural areasprimary treating physicianorthopedic physiciansoccupational health servicesLab. Code § 4600Lab. Code § 4616
References
5
Case No. ADJ7376647 (1-ARB-130005)
Regular
Apr 25, 2016

Christopher Santi vs. Contra Costa Electric, Zurich Insurance Co.

The applicant seeks reconsideration of an arbitrator's decision concerning a July 2009 industrial injury. The applicant argues the arbitrator erred by not considering his Chronic Regional Pain Syndrome (CRPS) diagnosis, which treating and defense physicians link to $100\%$ permanent total disability. The applicant also challenges the apportionment of psychiatric disability, contending the QME's report lacks substantial evidence. The Appeals Board granted reconsideration, rescinded the original award, and returned the case for further proceedings to allow the arbitrator to review critical evidence, specifically the deposition of the applicant's treating physician, and to address the CRPS findings.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardChronic Regional Pain SyndromeApportionmentQualified Medical ExaminerDepositionsMedical EvidencePermanent DisabilityTrial Level
References
1
Case No. ADJ11201712
Regular
Oct 12, 2018

JAMES MARINELLI vs. CITY OF PACIFICA NORTH COUNTY FIRE AUTHORITY

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration of a prior decision. The prior decision found the applicant was temporarily totally disabled from June 15, 2017, to November 9, 2017, and that he became permanent and stationary on November 9, 2017. The applicant argued that the primary treating physician's reports were not substantial evidence, but the Board found the reports from Dr. Nolan and Dr. Shaw also lacked substantiality due to inconsistencies and omissions. Furthermore, the applicant failed to properly follow dispute resolution procedures by unilaterally designating a new treating physician instead of utilizing the QME process.

Permanent and StationaryTemporary Disability IndemnityPrimary Treating PhysicianQualified Medical ExaminerSubstantial EvidencePetition for ReconsiderationFindings and OrderMedical TreatmentFunctional Capacity EvaluationAD Rule 9785(b)(3)
References
3
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