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

Case No. ADJ2969856 (SAL 0073653)
Regular
Apr 01, 2009

PINA vs. MEYER TOMATORES, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, INTERCARE

This case involves a defendant seeking reconsideration of findings that they failed to respond to a request for an epidural injection authorization and that a treating physician provided reasonable and necessary care. The Board dismissed a second petition concerning a WCJ's report, deeming it not a final order. The Board granted reconsideration of the initial petition solely to order the defendant to authorize the epidural injection. All other aspects of the original award were affirmed.

Workers Compensation Appeals BoardPetition for ReconsiderationEpidural InjectionReasonable and Necessary TreatmentUtilization ReviewBoard Rule §10510Floyd Skeren & KellyWCJ Report and RecommendationFinal OrderAggrieved Party
References
1
Case No. VNO 0504152
Regular
Feb 01, 2008

Debi Surgenor vs. RALPH'S GROCERY COMPANY, SEDGWICK CMS

The Workers' Compensation Appeals Board granted reconsideration to defer the issue of applicant's need for cervical epidural injections due to an inadequate trial record, specifically concerning claim and stipulations for a cervical injury. However, the Board affirmed the original finding that lumbar epidural injections are medically necessary to treat the applicant's industrial injury, supported by medical evidence and demonstrated benefit from prior treatment. The case highlights the importance of a complete and stipulated record for medical treatment claims in workers' compensation proceedings.

Workers' Compensation Appeals BoardRalph's Grocery CompanySedgwick CMSDebi Surgenorcervical epidural injectionslumbar epidural injectionsUtilization Review denialACOEM guidelinesradiculopathyelectrodiagnostic testing
References
1
Case No. ADJ2211743 (SBR 0330510)
Regular
Jul 19, 2011

LAURA GIBSON vs. FOREST HOME, INCORPORATED, CHURCH MUTUAL INSURANCE

The Workers' Compensation Appeals Board denied reconsideration of a lien claimant's petition regarding reimbursement for medical treatment. Although the petition was not acted upon within the statutory 60-day period, the Board considered it on its merits due to circumstances beyond the claimant's control. The WCJ's report, which was adopted by the Board, found that the lien claimant failed to meet the burden of proof for treatment beyond a single epidural injection. The Board determined that only charges attributable to a single epidural procedure were reasonable and necessary, excluding other procedures like facet blocks and manipulation under anesthesia.

WORKERS' COMPENSATION APPEALS BOARDLAURA GIBSONFOREST HOMEINCORPORATEDCHURCH MUTUAL INSURANCEORDER DENYING RECONSIDERATIONPetition for Reconsiderationlien claimantdue processWCJ report
References
1
Case No. SDO 0251396
Regular
May 19, 2008

KENN FINKELSTEIN vs. BUILDERS STAFF CORPORATION, CENTRE INSURANCE COMPANY

The applicant sought reconsideration of a prior Workers' Compensation Appeals Board decision that denied certain medications (Nexium, Lisinopril) and epidural steroid injections, while awarding Lipitor. The Board denied reconsideration, holding that the applicant failed to follow the proper statutory procedure for disputing the employer's utilization review denials. Although there was some question about the validity of the utilization review denial for the injections, the applicant's procedural failure was the decisive factor.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and Award/OrderAdministrative Law Judge (WCJ)Further Medical TreatmentPrescriptive MedicationLipitorNexiumLisinoprilEpidural Steroid Injections
References
5
Case No. ADJ1610169 (ANA 0403916)
Regular
Oct 29, 2010

MARIA ORTEGA vs. USNEYLAND RESORTS; DISNEY

This case concerns a petition for reconsideration by lien claimants challenging the disallowance of their medical liens. The initial administrative law judge disallowed the liens, finding a referral for epidural injections was not supported by evidence. Specifically, the judge noted a report by Dr. Ross, which in turn cited Dr. Trotter's opinion that post-permanent and stationary treatment, including injections, was not appropriate or necessary. The Workers' Compensation Appeals Board denied the petition for reconsideration.

Workers' Compensation Appeals BoardLien ClaimantsPetition for ReconsiderationDisallowed Lien ClaimsCompromise and ReleaseIndustrial InjuryHousekeeperBack InjuryAdministrative Law JudgeFindings and Order
References
0
Case No. ADJ1108219 (SAC 0310883)
Regular
Jun 01, 2009

WILLIAM SOWLES vs. COUNTY OF SACRAMENTO

The Workers' Compensation Appeals Board granted the defendant's Petition for Reconsideration regarding an award for an applicant's industrial back and psyche injury. While affirming the finding of injury and need for further medical treatment, the Board amended the decision to strike the defendant's liability for Dr. Burt's medical-legal reporting costs. The initial award had found the defendant improperly denied a lumbar epidural steroid injection and ordered payment for Dr. Burt's reports.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings Award OrdersIndustrial InjuryDeputy SheriffLumbar Epidural Steroid InjectionACOEM GuidelinesMedical-Legal ExpensesWCJ ReportDecision After Reconsideration
References
0
Case No. VNO 497379
Regular
Dec 27, 2007

AGNES MERCADO vs. AMERICAN DAWN, INC., HIGHLANDS INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration to correct errors in the original award to lien claimant S&B Surgery Center. The Board reduced the award for certain epidural injections and a lysis procedure based on corrected billing and relevance of the comparative study. Despite defendant's arguments, the Board affirmed the award of statutory interest on unpaid medical bills, finding the defendant failed to meet statutory requirements for contesting payment.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFindings and AwardEpidural BlocksLumbar DiscographyCompromise and ReleaseLabor Code Section 4603.2Medical TreatmentInterest
References
1
Case No. ADJ8032105
Regular
Jul 18, 2019

JACQUELINE DIXON vs. VEOLIA TRANSPORTATION, OLD REPUBLIC INSURANCE COMPANY

This Workers' Compensation Appeals Board case involves an applicant seeking reconsideration of a denial for epidural steroid injections. While the applicant's petition was initially filed late, the Board deemed it timely due to defective service of the prior order. Crucially, the applicant subsequently informed the Board that the Independent Medical Review (IMR) had approved the disputed treatment. Consequently, the applicant requested dismissal of their petition, which the Board granted, returning the matter to the trial level.

Jacqueline DixonVeolia TransportationOld Republic Insurance CompanySedgwick CMSADJ8032105Petition for ReconsiderationIndependent Medical Review (IMR)Epidural Steroid InjectionLabor Code section 4610.6(f)Medical Treatment Utilization Standards (MTUS)
References
2
Case No. ADJ2930104 (RIV 0061967)
Regular
Jan 19, 2017

LEONARDO NUNGARAY vs. REMEDIATION CONSTRUCTORS, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration of a prior decision concerning applicant Leonardo Nungaray's claim. The Board found that the initial Utilization Review (UR) determination erroneously characterized the applicant's requested treatment for a left-sided epidural injection as a right-sided procedure. This fundamental error in the UR process, not the Independent Medical Review (IMR), requires further examination. Consequently, the case is returned to the trial level to determine if the UR was timely and if the judge has jurisdiction over the medical necessity dispute.

Workers' Compensation Appeals BoardIndependent Medical ReviewPetition for ReconsiderationPlainly Erroneous Finding of FactRadiculopathyRequest for AuthorizationEpidural InjectionTreating PhysicianUtilization ReviewMedical Treatment Guidelines
References
0
Case No. ADJ7303882
Regular
Sep 11, 2014

ANTONIA HUERTA vs. HUENEME SCHOOL UNIFIED DISTRICT, YORK RISK SERVICES GROUP

This case concerns a hospital's claim for additional payment for an injured worker's lengthy rehabilitation stay following paraplegia after epidural injections. The hospital argued its services were exempt from the Official Medical Fee Schedule due to extraordinary circumstances and the necessity of specialized rehabilitation. The Workers' Compensation Appeals Board adopted the Administrative Law Judge's recommendation, denying the employer's petition for reconsideration. The Board found the ALJ's reasoning regarding reasonable treatment under the fee schedule and the justification for additional payment, including interest, was sound.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeReport and RecommendationStipulationsCustodianUpper ExtremitiesBackHipsLower Extremities
References
0
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