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

Case No. ADJ8436467
Regular
Sep 09, 2015

CELEINE MELENDEZ vs. KOHL'S DEPARTMENT STORE, NEW HAMPSHIRE INSURANCE COMPANY

This case concerns an employee seeking workers' compensation for back surgery, specifically an anterior lumbar discectomy and fusion. The employer contested the necessity of the surgery, arguing the administrative law judge erred in approving it. The Appeals Board affirmed the judge's decision, finding the request for authorization was valid as it reflected a change in circumstances. Therefore, the defendant is ordered to provide the authorized surgical treatment.

Workers' Compensation Appeals BoardReconsiderationUtilization ReviewAnterior Lumbar Discectomy and FusionLabor Code section 4610(g)(6)Primary Treating PhysicianIndependent Medical ReviewFindings and OrderLumbar SpineMedical Treatment Authorization
References
Case No. ADJ6619207 ADJ6736606
Regular
May 24, 2010

ALBERTO ALVAREZ vs. AKT DEVELOPMENT CORPORATIONS, INSURANCE OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration of a decision awarding lumbar fusion surgery, finding the WCJ erred by solely relying on the *Cervantes* decision regarding timely utilization review. The Board determined that the defendant's utilization review timeliness was unclear, and the parties had agreed to an Agreed Medical Examiner (AME) to resolve the surgery dispute before *Cervantes* was issued. Furthermore, the Board held that the treating physician's recommendation for surgery must constitute substantial evidence, which was not definitively established here. Therefore, the matter was returned for further development of the record, requiring the treating physician to address the AME's concerns regarding the necessity of fusion surgery.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationJoint Findings Award and OrderIndustrial InjuryLumbar FusionUtilization ReviewCervantes v. El Aguila Food ProductsSubstantial Medical EvidenceExpedited Hearing
References
Case No. ADJ9546300 ADJ9103215
Regular
Apr 21, 2015

JAMES TUBBS vs. FRESNO CHAFFEE ZOO, NATIONWIDE AGRIBUSINESS INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and reversed a prior decision, finding the applicant is not entitled to a second lumbar surgery. The WCAB concluded that the applicant failed to meet the burden of proof by providing substantial medical evidence demonstrating the surgery's reasonableness and necessity, as required by Labor Code sections 5705 and 4600. While acknowledging the prior successful surgery, the WCAB found Dr. Aryan's request lacked sufficient support based on established medical treatment guidelines. The dissenting opinion argued that substantial medical evidence supported the surgery and that the defendant's delays unfairly prejudiced the applicant.

ADJ9546300ADJ9103215lumbar spine injuryDr. Francisco UnguezDr. Henry AryanRequest for Authorization (RFA)surgery authorizationL4-S1 surgeryDubon IIsubstantial medical evidence
References
Case No. ADJ7951527
Regular
Oct 03, 2016

RONALD COYLE vs. DANE COYLE CUSTOM HOMES, INC.

The defendant sought reconsideration of an award for an applicant's industrial back injury, challenging the timeliness of the utilization review (UR) denial and the necessity of proposed spinal surgery. The Board denied reconsideration, affirming that the defendant failed to prove timely communication of the UR denial as required by law. Furthermore, substantial evidence, including reports from the treating physician and Agreed Medical Evaluator, supported the necessity of the lumbar fusion surgery. The Board found the defendant's arguments insufficient to rebut the expert medical opinions presented.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryUtilization Review (UR) DenialTimelinessFurther Medical TreatmentSpinal SurgeryLumbar FusionRequest for Authorization (RFA)
References
Case No. ADJ10034122
Regular
Dec 22, 2017

CRYSTAL WYANT vs. AMERICAN MEDICAL RESPONSE, ACE AMERICAN INSURANCE COMPANY

This case concerns an applicant's industrial back injury requiring lumbar spinal fusion. Defendants sought to overturn a prior award granting ongoing medical treatment, arguing a subsequent Utilization Review (UR) certification was invalid. The Appeals Board denied reconsideration, finding the UR process was correctly followed. A second Request for Authorization (RFA) submitted by the applicant's physician included "Change in Material Facts," triggering a new review. This second UR decision, dated September 11, 2017, authorized the surgery as medically necessary, superseding the earlier denial.

Utilization ReviewIndependent Medical ReviewReconsiderationFindings and AwardAdministrative Law JudgeLabor Code Section 4610Request for AuthorizationLumbar Spinal FusionMedical TreatmentChange in Material Facts
References
Case No. ADJ4695633 (OXN 0133122)
Regular
Oct 14, 2013

DEBRA CHELI vs. CHICO'S; HARTFORD INSURANCE, administered by BROADSPIRE

The Workers' Compensation Appeals Board denied a petition for reconsideration, upholding the findings of the administrative law judge. The judge's decision relied heavily on the credibility of the applicant and the opinion of an agreed medical examiner who found no apportionment to prior or subsequent injuries. The Board agreed with the judge that the medical examiner's opinion was persuasive, noting that the petitioner failed to provide sufficient evidence to challenge it. Therefore, the petition for reconsideration was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationAgreed Medical ExaminerApportionmentSubstantial EvidencePermanent Total DisabilityWCJMedical ReportLumbar FusionCumulative Trauma
References
Case No. ADJ7669411
Regular
Jul 23, 2013

OSCAR HUERTA vs. HIGGINS & LOVETT CONSTRUCTION, TOWER SELECT INSURANCE CO.

This case involves a workers' compensation claim for a laborer injured on November 2, 2010, to his neck and back. The defendant disputes the finding of 51% permanent disability, primarily arguing that the panel qualified medical evaluator's (PQME) report was not substantial evidence. The Appeals Board has granted reconsideration to further review the PQME's lumbar impairment rating, specifically questioning whether "non-verifiable radicular complaints" sufficiently supported the DRE Category III rating. The Board has rescinded the prior award and returned the case for further development of the record.

Occupational Group 480Panel Qualified Medical Evaluator (PQME)Dr. DawdyDRE Category IIIRadiculopathyLumbar ImpairmentSubstantial Medical EvidenceFurther Development of the RecordAmended Findings and AwardLumbar Spine
References
Case No. ADJ7329727
Regular
Oct 10, 2014

KRISSY KORN vs. ENTERTAINMENT PARTNERS, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

The Workers' Compensation Appeals Board denied the employer's petition for reconsideration of an award for back surgery. The Board adopted the WCJ's report, except for a comment regarding the defendant's burden of proof on MTUS compliance. The Board clarified that the applicant bears the burden of proving the reasonableness of requested treatment. The employer's argument for denying the surgery based on lack of substantial medical evidence was rejected.

WORKERS' COMPENSATION APPEALS BOARDPetition for ReconsiderationWCJ reportDubon v. World RestorationApplicant burden of proofmedical treatment utilization schedulelow backright shoulderCraft Services Personanterior lumbar interbody fusion
References
Case No. ADJ6527507
Regular
Oct 18, 2010

Wayne Moore vs. EAST BAY MUNICIPAL UTILITY DISTRICT, ATHENS ADMINISTRATORS

The Appeals Board granted reconsideration, finding the WCJ improperly substituted his medical judgment for the Qualified Medical Evaluator's (QME) regarding the applicant's industrial sleep disturbance. The WCJ's finding of no industrial sleep impairment, despite the QME's opinion indicating such, was deemed erroneous. The Board rescinded the original award and remanded the case for a new rating that incorporates the QME's findings on sleep disturbance. Additionally, the WCJ must correct an identified occupational group number error in future rating calculations.

Workers' Compensation Appeals BoardWayne MooreEast Bay Municipal Utility DistrictAthens Administratorsmachinist maintenance workermachinistmachinist maintenancepermanent disabilityapportionmentQualified Medical Evaluator
References
Case No. ADJ1489633 (SBR 0317521)
Regular
Dec 11, 2008

STEPHANIE ROECKER vs. MONO LAKE FOUNDATIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and affirmed an award, but amended the finding on temporary disability. The Board agreed with the defendant that the applicant was adequately compensated for temporary disability per stipulation. However, the Board upheld the use of the pre-2005 permanent disability rating schedule, finding substantial medical evidence existed prior to January 1, 2005, supporting this determination.

WCABPermanent Disability Rating ScheduleTemporary Total DisabilityFindings and AwardOrder of CommutationPost Fusion RadiculopathyIndustrial InjuryMedical TreatmentStipulationReconsideration
References
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