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

Case No. FRE 191206
Regular
Nov 20, 2007

MARY SEPEDA vs. SEPEDA BROTHERS DAIRY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION on behalf of FREMONT INDEMNITY, in liquidation, REPUBLIC INDEMNITY

This case involves an applicant seeking reconsideration of a workers' compensation award concerning a low back injury sustained through July 13, 1995. The applicant, supported by her treating physician, argued for additional disc replacement surgery at the L4-5 level beyond the previously awarded L5-S1 spinal fusion. The Workers' Compensation Appeals Board granted reconsideration and amended the award to include the L4-5 disc replacement surgery, finding it reasonably required to cure or relieve the applicant's injury based on the treating physician's opinion.

CIGAFremont IndemnityRepublic Indemnitylow back injurypermanent disabilityfurther medical treatmentspinal surgeryL5-S1 fusionL4-5 disc replacementtreating physician
References
2
Case No. SAC 286368
Regular
Jan 25, 2008

DALE OLIVER vs. BRIAN WILLIAMS CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking approval for disc replacement surgery for a work-related back injury. The defendant argued the surgery is experimental per ACOEM guidelines, thus not covered. The Board denied reconsideration, finding the applicant's physician rebutted the presumption of experimental status. The Board determined the surgery is no longer experimental, citing FDA approval, and is reasonably required for the applicant's specific condition, supported by expert medical opinion.

Workers' Compensation Appeals BoardBrian Williams ConstructionState Compensation Insurance Fundindustrial injuryright anklefootelbowshoulderskneesleft lower extremity
References
0
Case No. ADJ9366278
Regular
Nov 18, 2014

JASON ALLEN vs. PROVIDENCE HOLY CROSS HOSPITAL

This case involves a defendant hospital's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The WCAB previously found the hospital's utilization review denial untimely, thus retaining jurisdiction to determine the necessity of the applicant's artificial disc replacement surgery. The WCAB affirmed the finding that the surgery was reasonably necessary, amending the basis for the untimely denial to focus on service notification errors. The defendant argued the administrative rules regarding notification to counsel conflicted with Labor Code section 4610, but the WCAB found no such conflict, upholding its prior decision.

Workers' Compensation Appeals BoardUtilization ReviewTimelinessJurisdictionArtificial Disc ReplacementMedical NecessityPrimary Treating PhysicianAdministrative RulesLabor CodeIndependent Medical Review
References
3
Case No. MISSING
Regular Panel Decision

Claim of Mallette v. Flattery's

A claimant, who had a preexisting lower back condition and had been recommended for artificial disc replacement surgery (ADRE), suffered further lower back injuries in a work accident in 2010. A Workers’ Compensation Law Judge initially apportioned liability for the ADRE equally between the preexisting condition and the work accident. However, the Workers’ Compensation Board modified this, finding the employer's carrier solely liable for the surgery. The carrier appealed, arguing a lack of causal relationship between the accident and the need for ADRE. The Appellate Division affirmed the Board's decision, concluding that substantial evidence supported the finding that the work accident aggravated the claimant's preexisting condition, making the need for ADRE causally related to the accident.

workers' compensationcausal relationshipaggravation of preexisting conditionartificial disc replacement surgerylower back injuryapportionmentmedical authorizationsubstantial evidenceBoard determinationAppellate Division decision
References
5
Case No. 531582
Regular Panel Decision
May 13, 2021

Matter of Matteliano v. Trinity Health Corp.

Caitlyn Matteliano, a nurse assistant, suffered work-related back, knee, and leg injuries in 2015 and 2018. Her treating orthopedic surgeon, Franco Vigna, requested authorization for multi-level lumbar fusion surgery and an external bone growth stimulator due to persistent pain and degenerative disc disease, despite conservative treatments. The employer denied this request based on an independent medical examination by Anthony Leone, who deemed the surgery aggressive and inappropriate given the lack of instability. A Workers' Compensation Law Judge initially denied the request, but the Workers' Compensation Board approved it. The employer appealed, and the Appellate Division, Third Department, affirmed the Board's decision, finding substantial evidence in Vigna's testimony to support the surgery's authorization under medical treatment guidelines for degenerative disc disease where non-surgical management has failed.

Workers' CompensationLumbar Fusion SurgeryMedical Treatment GuidelinesDegenerative Disc DiseaseDiscogenic Back PainIndependent Medical ExaminationPrior AuthorizationAppellate ReviewNurse AssistantWork Injury
References
9
Case No. MISSING
Regular Panel Decision

Claim of Prescott v. Town of Lake Luzerne

A claimant fell off a dump truck at work in February 2008, landing on his right buttock and injuring his hip. The injury led to surgery in May 2008 to remove heterotopic bone and subsequent two-stage hip replacement revision surgeries in November 2008 and February 2009 due to an infection. The Workers’ Compensation Board found the initial surgery and subsequent revisions causally related to the work fall and supported compensation awards. The employer appealed, arguing that an independent medical examination (IME) was improperly precluded and that the initial surgery lacked proper authorization. The Appellate Division affirmed the preclusion of the IME due to untimeliness and upheld the causal relationship findings for the injury and subsequent surgeries. However, the court reversed the Board's determination that the May 2008 surgery was properly authorized, remitting that specific issue for further proceedings, while affirming all other appealed decisions.

Causal RelationshipIndependent Medical Examination (IME)Evidence PreclusionSurgery AuthorizationHip InjuryHeterotopic OssificationMedical Opinion ConflictDue ProcessRemittiturEmployer Liability
References
8
Case No. ADJ9179881
Regular
Dec 19, 2014

CURTIS MAUCH vs. CITY OF LODI, YORK RISK SERVICES GROUP, INC.

Here's a summary of the case for a lawyer in four sentences: The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration, upholding the prior decision that required liability for necessary medical treatment. This liability is specifically limited to treatment enabling knee replacement surgery, not for subsequent conditions. The Board adopted the WCJ's reasoning, citing *Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd.* to support the decision. The case involved an applicant needing knee replacement surgery, and the defendant argued that a separate cardiac defibrillator issue was unrelated to the industrial injury.

Petition for ReconsiderationWorkers' Compensation Appeals BoardCity of LodiYork Risk Services GroupAdministrative Law JudgeKnee replacement surgeryCardiac defibrillatorBraewood Convalescent HospitalLabor Code Section 5903Myers
References
8
Case No. MISSING
Regular Panel Decision
Jun 02, 2008

Claim of Laezzo v. New York State Thruway Authority

The claimant suffered a work-related slip and fall in 2002, leading to injuries including his head, neck, back, and knees. His morbid obesity contributed to his back and knee issues, prompting him to seek authorization for gastric bypass surgery. The Workers’ Compensation Law Judge approved the surgery, a decision affirmed by the Workers’ Compensation Board, which found the surgery causally related to the compensable injuries. The employer and its carrier appealed, challenging the causal link. The court affirmed the Board's decision, noting substantial evidence that the claimant's weight gain was a result of the sedentary lifestyle imposed by his injuries, and that the surgery would aid in his recovery.

Workers' CompensationConsequential InjuryGastric Bypass SurgeryMorbid ObesityMedical Treatment AuthorizationCausationKnee InjuryBack InjurySedentary LifestyleBoard Decision Appeal
References
2
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
6
Case No. ADJ4016735 (BAK 0147536)
Regular
Jun 11, 2012

COLLEEN PARHAM vs. KERN RADIOLOGY MEDICAL GROUP, LEGION INSURANCE GROUP

This case involves an applicant seeking bilateral knee replacement surgery due to an admitted industrial back injury. The applicant argues the surgery is necessary to enable further treatment for her back, specifically a spinal cord stimulator. The defendants contested this, claiming the knee condition was independent and unrelated to the industrial injury. The Appeals Board granted reconsideration, finding the knee surgery reasonably required to relieve the industrial back injury, citing *Bolton* and *Rowan*, even if the knee condition itself was not industrial. The Board rescinded prior findings, awarding the knee surgery and deferring issues of permanent disability and temporary disability.

Workers' Compensation Appeals BoardReconsiderationFindings of FactBilateral Knee ReplacementIndustrial InjuryBack InjurySpinal Cord StimulatorTemporary Total DisabilityPermanent and StationaryQualified Medical Evaluator
References
8
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