CompFox Logo
AboutWorkflowFeaturesPricingCase LawInsights

Updated Daily

Case Law Database

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

Case No. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
Case No. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
Case No. ADJ1003604 (VNO 0473994)
Regular
May 10, 2016

MARIO CARRASCO vs. CITY OF LOS ANGELES

Lien claimant Western Medical Center (Western) sought reconsideration of an Independent Bill Review (IBR) determination that found no reimbursement warranted for medical services. Western argued the IBR determination was plainly erroneous because the defendant failed to provide a contract justifying payment below the official medical fee schedule. However, the Board dismissed Western's petition, finding it premature and improperly filed. Western failed to exhaust the required statutory appeal process to the Workers' Compensation Appeals Board trial level before filing for reconsideration.

Workers' Compensation Appeals BoardIndependent Bill ReviewAdministrative DirectorMaximus Federal ServicesOfficial Medical Fee ScheduleStipulations and AwardCumulative Trauma InjuryLumbar Spinal SurgerySecond Bill ReviewExplanation of Benefits
References
Case No. ADJ1634986
Regular
Sep 10, 2013

REGINA CAMACHO vs. RIO SCHOOL DISTRICT, YORK INSURANCE SERVICES

This Workers' Compensation Appeals Board decision denies a lien claimant's petition for reconsideration. The lien claimant, Pueblo Surgery Center, failed to meet its burden of proof to establish the reasonableness of its $18,940.00 surgical charges. The Board adopted the WCJ's reasoning that Pueblo's submitted exhibits lacked necessary substantiation and were insufficient to prove their charges were reasonable. Therefore, the denial of reconsideration stands, upholding the original determination regarding the lien claim.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantReasonableness of ChargesOutpatient Surgery CenterBillingDeclarations Under Penalty of PerjuryComparative BillingBurden of ProofIndependent Bill Review
References
Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
Case No. ADJ1852772 (VNO 0450819) ADJ3998532 (VNO 0450822)
Regular
Jan 19, 2011

A. JOY SKEETE-PENEGAR vs. BANK OF AMERICA, ARROWOOD INDEMNITY

The Workers' Compensation Appeals Board (WCAB) denied a Petition for Removal filed by Lien Claimants David Silver, MD and David Bresler, PhD. The Petitioners argued the defendant's bill reviewer's testimony should be excluded and that continuing the trial was improper. The WCAB found no final order had been issued regarding the bill reviewer's expertise or fee entitlement, thus no significant prejudice or irreparable harm occurred. Therefore, removal was inappropriate, and the WCAB adopted the Judge's report recommending denial.

Workers' Compensation Appeals BoardPetition for RemovalLien ClaimantWorkers' Compensation Administrative Law JudgeOfficial Medical Fee ScheduleBill ReviewerExpert WitnessIrreparable HarmLabor Code Section 10843Continuance
References
Case No. ADJ3496351 (SAC 0319422)
Regular
Sep 27, 2010

SANDRA L. BOYD vs. COUNTY OF SACRAMENTO

This case concerns whether lien claimant MBM Boutique Acupuncture could bill for multiple units of electro-acupuncture (CPT code 97801) per session. The defendant, County of Sacramento, argued that under the Official Medical Fee Schedule (OMFS), 97801 is an untimed code billable only once per session. The Appeals Board reversed the WCJ's decision, finding the defendant's expert bill reviewer's unrebutted testimony established 97801 as an untimed code, limiting reimbursement to one unit per session. Therefore, the defendant's payment was deemed reasonable and consistent with the OMFS, and the lien claimant was awarded nothing further.

Official Medical Fee ScheduleOMFS97801timed proceduresuntimed proceduresdeputy sheriffacupuncturereimbursementbill reviewerunit per session
References
Case No. ADJ9615494
Regular
Oct 08, 2019

CARLOS SOTO TORRES vs. THE CLIFF RESTAURANT, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded an Amended Findings of Fact and Order because essential documentation regarding the timeliness of medical-legal billings and reviews was missing. Specifically, the record lacked proof of service for the provider's invoice, the defendant's initial Explanation of Review (EOR), and the subsequent second bill review. This prevented determination of whether the defendant timely objected to the bill and whether the provider timely requested a second review, necessitating further proceedings at the trial level.

Workers' Compensation Appeals BoardReconsiderationAmended Findings of Fact and OrderQualified Medical EvaluatorQMEDr. Payam MoazzazZenith Insurance CompanyStatute of LimitationsLabor Code section 4903.5Independent Bill Review
References
Case No. ADJ8485371
Regular
Dec 01, 2014

MICHAEL (MIKE) STRATTON vs. SAN DIEGO CHARGERS, ZENITH NORTH AMERICA, BUFFALO BILLS

The Workers' Compensation Appeals Board reconsidered a prior decision regarding Michael Stratton's cumulative injury claim against the San Diego Chargers and Buffalo Bills. While the original judge found Stratton's claim against the Bills timely, the Board reversed this, determining it was barred by the statute of limitations. The Board found that neither employer breached a duty to notify Stratton of his workers' compensation rights at the time of his employment. Therefore, the statute of limitations was not tolled, and Stratton's claim against the Buffalo Bills is dismissed.

WCABStatute of LimitationsLabor Code Section 5405Date of InjuryTollingCumulative InjuryProfessional Football PlayerSan Diego ChargersBuffalo BillsZenith North America
References
Case No. ADJ8824674
Regular
Mar 15, 2018

MIGUEL MONTES vs. KOLE, INC. DBA QUALITY TUNE UP #8, ILLINOIS MIDWEST INSURANCE AGENCY, LLC, PROCENTURY INSURANCE COMPANY

This case concerns a Petition for Removal that the Workers' Compensation Appeals Board (WCAB) dismissed as untimely. The petitioner failed to file their removal petition within the prescribed 20-day period plus additional mailing time, submitting it one day late. Even if timely, the WCAB would have denied it on the merits, agreeing with the WCJ that the billing dispute was subject to Independent Bill Review (IBR) and not the WCAB's jurisdiction. The WCAB emphasized that if the sole dispute is the amount of payment and a second review failed, IBR is the proper avenue under Labor Code section 4603.6.

Petition for RemovalWorkers' Compensation Appeals BoardUntimely FilingService of OrderLegal MailingIndependent Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.6Medical Provider NetworkJurisdiction
References
Showing 1-10 of 451 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.

CompFox Logo

The AI standard for workers' compensation professionals. Faster research, deeper analysis, better outcomes.

Product

  • Platform
  • Workflow
  • Features
  • Pricing

Solutions

  • Defense Firms
  • Applicants' Attorneys
  • Insurance carriers
  • Medical Providers

Company

  • About
  • Insights
  • Case Law

Legal

  • Privacy
  • Terms
  • Trust
  • Cookies
  • Subscription

© 2026 CompFox Inc. All rights reserved.

Systems Operational