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

Case No. ADJ8765068, ADJ8765078, ADJ8841406
Regular
Nov 18, 2015

WILLIAM MCBURNEY vs. ALL THAT GLITTERS, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) is granting reconsideration on its own motion to correct a clerical error in a prior decision. The error incorrectly identified the physician authorized for surgery; the original decision will be affirmed with this correction. Specifically, Order A is amended to authorize Michael Laird, M.D. for a left total knee arthroplasty, not Dr. James Strait.

Workers' Compensation Appeals BoardReconsiderationClerical ErrorAgreed Medical EvaluatorPrimary Treating PhysicianLeft Total Knee ArthroplastyJoint Findings and OrderFindings of Fact Award and OrdersOpinion and Decision After ReconsiderationSan Luis Obispo
References
Case No. ADJ8858239, ADJ8858240
Regular
Oct 13, 2016

ANTOINETTE MIRANDA vs. CALIFORNIA DEPARTMENT OF CORRECTIONS, legally uninsured

This case concerns the timeliness of an Independent Medical Review (IMR) determination for a left knee total arthroplasty. The WCJ found the IMR determination was late and the WCAB had jurisdiction, but denied the surgery due to insufficient evidence of medical necessity. The Appeals Board granted reconsideration, affirming the denial of treatment but clarifying that the timeframe for IMR issuance under Labor Code section 4610.6(d) is directory, not mandatory. Therefore, the late IMR determination is valid, and the applicant is bound by its decision regarding the medical necessity of the proposed surgery.

Independent Medical ReviewUtilization ReviewLabor Code Section 4610.6(d)Directory vs. Mandatory TimeframeMedical NecessityLeft Knee Total ArthroplastyWCJWCABPetition for ReconsiderationReport and Recommendation
References
Case No. ADJ11602449
Regular
Apr 01, 2020

PAUL PENNINGTON vs. WALMART STORE, INC.

This case involves an applicant who sustained left knee and right great toe injuries while employed by Walmart. The Workers' Compensation Appeals Board granted reconsideration to review the administrative law judge's (WCJ) decision regarding permanent disability. The Board found that the WCJ improperly made his own apportionment determination instead of relying on the QME's opinion, which was deemed substantial medical evidence. Consequently, the Board amended the award to reflect 37% permanent partial disability, increasing the applicant's indemnity and adjusting the attorney's fee accordingly.

Workers' Compensation Appeals BoardReconsiderationPermanent DisabilityApportionmentQualified Medical ExaminerAMA GuidesWhole Person ImpairmentSubstantial EvidenceMedical OpinionCausation
References
Case No. ANA 0393414
Regular
May 27, 2008

REBECCA CHRISTENSEN vs. NEWPORT-MESA UNIFIED SCHOOL DISTRICT

The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior award because the medical evidence was insufficient to support the 45% permanent disability rating. The Board found that the judge's reliance on combining subjective pain complaints with objective findings, without proper medical expert guidance, and the rating specialist's application of instructions were not supported by substantial medical evidence. The case is returned to the trial level for further development of the medical record.

Workers' Compensation Appeals BoardSpecial Education Bus DriverIndustrial InjuryRight ShoulderRight ArmPermanent Disability RatingAMA GuidesRotator Cuff RepairArthroplastyMumford Procedure
References
Case No. ADJ9917212
Regular
Mar 17, 2016

MICHAEL GREEN vs. ELLE PLACEMENT dba GOLDEN GATE STAFFING, LUMBERMEN'S UNDERWRITING ALLIANCE

This case concerns the timeliness of a defendant's utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) rescinded the initial decision awarding treatment, finding the defendant's UR denial was timely made and served within the five-business-day window. The key issue was whether a UR denial sent via facsimile after 5:30 p.m. on the fifth business day was valid. The Board concluded the UR decision was timely made and communicated within 24 hours of its making, rendering it valid and requiring disputes to go through the Independent Medical Review (IMR) process.

Utilization ReviewRequest for AuthorizationIndependent Medical ReviewWCJBusiness DayFacsimile Date StampAdministrative DirectorMedical TreatmentSpinal SurgeryArthroplasty
References
Case No. ADJ8032740
Regular
Sep 17, 2014

LAURA RAMIREZ vs. LOYOLA MARYMOUNT UNIVERSITY, TRAVELERS

This case involved a custodian injured on the job, causing admitted industrial injury to her knee and lumbar spine. The Administrative Law Judge apportioned 50% of the permanent disability to pre-existing arthritis, a decision the applicant contested. The Workers' Compensation Appeals Board denied reconsideration, finding the apportionment supported by medical evidence indicating the industrial injury and pre-existing arthritis jointly necessitated knee replacement surgery. This aligns with precedent requiring apportionment to all causative factors, including underlying pathology.

ApportionmentPre-existing arthritisIndustrial injuryPermanent disabilityWCJPetition for reconsiderationLabor Code 4663PQMEOrthopaedic surgeonArthroplasty
References
Case No. ADJ4582135
Regular
Dec 16, 2011

AMALIA ANAYA vs. CITY OF SOUTH GATE, CHARTIS INSURANCE COMPANY

The applicant sought reconsideration of a WCJ's decision denying further permanent disability benefits beyond the initial award of April 19, 2000. The applicant argued the WCJ erred by relying on Dr. Silbart's QME report and by not awarding temporary disability based on a treating physician's report for a knee replacement. The Appeals Board denied reconsideration, finding Dr. Silbart's opinion provided substantial evidence for the decision. The Board further determined that the treating physician's vocational conclusion lacked substantial evidence as he was not a vocational expert.

Petition to ReopenPermanent DisabilityTemporary DisabilityQualified Medical EvaluationTreating PhysicianPermanent and StationaryNew and Further DisabilityStipulated AwardVocational ExpertSubstantial Evidence
References
Case No. ADJ10986659
Regular
Sep 30, 2025

ALFREDO SERRANO vs. BIG IDEA HOLDINGS, LLC; OLD REPUBLIC INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration to further study the legal and factual issues raised by the Petition for Reconsideration. Applicant sought reconsideration of the January 27, 2022 Findings and Award, challenging the findings regarding a specific industrial injury to his right shoulder and a claimed cumulative injury. The Board concluded that the medical-legal opinions of the Qualified Medical Evaluator (QME), Dr. Bruce Huffer, were legally insufficient and analytically incomplete because he applied an incorrect legal standard for causation and apportionment, repeatedly requiring 'certainty' instead of 'reasonable medical probability'. Consequently, the Board rescinded the F&A and returned the matter to the trial level for further development of the medical-legal record, suggesting the selection of an Agreed Medical Evaluator.

QMEcumulative injuryapportionmentarthroplastysubstantial evidencemedical-legal opinionsrecord developmentLabor Code section 5701reasonable medical probabilitysuperimposed injury
References
Case No. ADJ8419958
Regular
Jan 16, 2014

FELIPE RAMIREZ vs. D'ARCY & HARTY CONSTRUCTION, INC., OLD REPUBLIC GENERAL INSURANCE CORPORATION

This case involves a worker's compensation applicant, Felipe Ramirez, seeking approval for spinal surgery recommended by his treating physician, Dr. Naraghi. The defendants contested the surgery, and Utilization Review initially denied the request. The Administrative Law Judge (ALJ) awarded the surgery, finding the UR denial invalid as the reviewing doctor lacked crucial medical information. The Appeals Board denied the defendants' petition for reconsideration, affirming the ALJ's decision.

Workers' Compensation Appeals BoardPetition for ReconsiderationDenialSpinal surgeryDr. NaraghiUtilization ReviewNon-certificationDr. DeutschSandhagenLabor Code §4610
References
Case No. ADJ14941977
Regular
Mar 27, 2023

ARTHUR ORCUTT vs. OAK HILL LOGISTICS, SERVICE AMERICAN INDEMNITY CO., SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The petition was deemed untimely as it was filed 25 days after the Findings and Award, exceeding the statutory 20-day limit. The Board adopted the Administrative Law Judge's report, which found the defendant's arguments regarding the timeliness of a Utilization Review denial and a violation of Labor Code §4600.4 to be without merit. Furthermore, the Judge's finding that the requested medical treatment was reasonable and necessary was upheld, despite the defendant's contentions regarding the applicant's balance issues.

WCABPetition for ReconsiderationDeniedFindings and AwardLabor Code § 5900Labor Code § 5903Cal. Code Regs. tit. 8 § 10605EAMSuntimely petitionUR denial
References
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