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

Case No. MISSING
Regular Panel Decision

Claim of Casiano v. CCIP/Union Settlement Home Care

In March 2001, claimant sustained a work-related back injury. Neurosurgeon Richard J. Radna recommended and performed decompression surgery despite the workers' compensation carrier denying preauthorization for the procedure. Both a Workers’ Compensation Law Judge and the Workers’ Compensation Board subsequently ruled that the surgery was not medically necessary, thereby absolving the carrier of liability for its cost. Claimant and Radna appealed this determination to the appellate court. Radna's appeal was dismissed due to lack of standing, and the Board's decision was affirmed, as it was within its purview to resolve the conflicting medical evidence presented by Radna and the carrier's neurosurgeon regarding the necessity of the surgery.

Workers' Compensation LawMedical NecessitySurgical ProcedurePreauthorization DenialNeurological InjuryConflicting Medical OpinionsAppellate ReviewStanding IssueCarrier LiabilityBack Injury
References
3
Case No. ADJ873701 (ANA 0299104) ADJ1741214 (ANA 0299113)
Regular
Sep 04, 2018

SHELLEE SMITH vs. SMITH'S FOOD AND DRUG, a subsidiary of the Kroger Company, permissibly self-insured, administered by SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves an untimely denial of a request for zolpidem by the defendant employer. The Workers' Compensation Appeals Board (WCAB) granted reconsideration because the trial judge's decision on medical necessity lacked substantial evidence due to a missing medical report. The matter is returned to the trial level to determine the reasonableness and necessity of the zolpidem treatment based on the correct evidence. The WCAB clarified that even with an untimely denial, the applicant must still prove the medical necessity of the requested treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardZolpidemUtilization ReviewIndependent Medical ReviewRequest for AuthorizationUntimely DenialMedical NecessityBurden of Proof
References
4
Case No. ADJ900432 (SAC 0323091)
Regular
Dec 30, 2011

MARLENE COPUS vs. NORTH SACRAMENTO ELEMENTARY SCHOOL DISTRICT

This case involves a dispute over the necessity of spinal surgery for an applicant who sustained a cumulative trauma injury to her neck and back. While the applicant's treating physician recommended surgery, a second opinion physician disagreed, citing a lack of nerve root compression. The Appeals Board found that the medical evidence was insufficient to determine the necessity of surgery, particularly in light of ACOEM Practice Guidelines which generally recommend against surgery without nerve root compression. Therefore, the Board rescinded the prior award and remanded the case to appoint an independent physician to evaluate the applicant and determine the reasonableness and necessity of the proposed surgery.

Workers' Compensation Appeals BoardMarlene CopusNorth Sacramento Elementary School Districtcumulative traumaspinal surgerynerve root impingementcervical stenosisDr. OrisekDr. GregoriusACOEM Practice Guidelines
References
4
Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)
En Banc
Feb 27, 2014

JOSE DUBON vs. WORLD RESTORATION, INC.; STATE COMPENSATION INSURANCE FUND

The WCAB holds that it has jurisdiction over disputes regarding the procedural validity and timeliness of utilization review (UR) decisions, while Independent Medical Review (IMR) is solely for resolving medical necessity. A UR decision with material procedural defects is invalid, and in such cases, the WCAB, not IMR, will determine the medical necessity of the treatment.

Utilization ReviewIndependent Medical ReviewEn Banc DecisionWCAB JurisdictionProcedural DefectsMedical NecessityLabor Code Section 4610Substantial Medical EvidenceMaterial Procedural DefectsInvalid UR Decision
References
17
Case No. GRO 23394 GRO 29090
Regular
Mar 18, 2008

LUISA H. GARCIA vs. FOSTER ASSESSMENT, STATE COMPENSATION INSURANCE FUND

The applicant sought reimbursement for a vocational expert's report used to challenge the applicable permanent disability rating schedule. The Appeals Board affirmed the WCJ's finding that the defendant was not liable for the cost of the report because the applicant failed to prove its necessity at the time it was incurred. The Board cited precedent holding that such costs are only reimbursable if reasonable and necessary, and the applicant did not demonstrate necessity for this particular report.

Workers' Compensation Appeals BoardPetition for Reconsiderationpermanent disability rating scheduleLabor Code section 5811reimbursement for costsvocational rehabilitation expertdiminished earning capacityMandatory Settlement Conferenceaffirmative burden of proofjudicial authority
References
1
Case No. ADJ10405277
Regular
Aug 10, 2018

JULIE VISH vs. SHARP HEALTH, ACE INSURANCE

The Workers' Compensation Appeals Board granted reconsideration and rescinded an earlier award ordering the defendant to authorize a nurse case manager. The Board found that the applicant's treating physician's recommendation for a nurse case manager, citing "complexity" and "miscommunication," lacked the specific medical reasoning required to establish necessity. The current ruling emphasizes that the applicant bears the burden of proving medical necessity through detailed evidence.

Nurse case managerUtilization reviewSubstantial medical evidenceMedical necessityLamin v. City of Los AngelesLabor Code section 4600(a)CausationCompensable injuryOpinion and OrderPetition for Reconsideration
References
4
Case No. ADJ1369119
Regular
Feb 17, 2016

CONNIE SHEPARD THOMPSON vs. COUNTY OF LOS ANGELES

This case concerns a dispute over the necessity of applicant's proposed back surgery. The Appeals Board granted reconsideration, finding that the defendant's Utilization Review denial was untimely communicated and thus invalid. However, the Board ultimately rescinded the WCJ's award of surgery because applicant's medical evidence from Dr. Spayde lacked substantial justification and did not demonstrate the surgery's reasonableness or necessity according to established standards. Therefore, the applicant was denied the requested surgical treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization ReviewNon-CertificationAdministrative Director RuleLabor CodeBodam v. San Bernardino CountyDubon v. World RestorationMedical TreatmentSubstantial Medical Evidence
References
2
Case No. ADJ4016080 (VNO 0496113)
Regular
Sep 08, 2009

SUZANNE KUYUMDZHYAN vs. JONS MARKETPLACE, ZURICH NORTH AMERICA

The Appeals Board granted reconsideration for both the defendant and lien claimant concerning an Amended Findings and Award. The original decision awarded the lien claimant payment for 18.5 hours of interpreting services, but the defendant argued the lien claimant failed to prove reasonableness and necessity of the services. The Board found the record undeveloped regarding the reasonableness and necessity of Dr. Rahimi's treatment and consequently, the derivative interpreting services. Therefore, the matter is remanded to the trial level for further proceedings to develop the record on these issues.

Workers' Compensation Appeals BoardPetition for ReconsiderationAmended Findings and AwardLien claimantInterpreting servicesCertified interpreterReasonable and necessary treatmentMedical-legal reportsCompromise and ReleaseBurden of proof
References
10
Case No. ADJ8797871
Regular
May 01, 2018

JUAN GARCIA vs. SIX PAC RECYCLING CORP., INSURANCE COMPANY OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration for lien claimant California Imaging Solutions, overturning the WCJ's denial of their lien. The Board found the lien claimant met its burden of proof regarding the necessity of services for a contested claim. Crucially, the defendant failed to properly contest the reasonableness and necessity of the lien claimant's copying services within the statutory timeframe and through required Explanation of Review forms. Therefore, the case is returned to the WCJ for further proceedings to determine the exact amount due to the lien claimant.

Medical-legal expensesLien claimantContested claimReasonableness and necessityLabor Code section 4622WCAB Rule 10451.1Explanation of Review (EOR)Subpoena Duces TecumKunz/market rate invoicesCompromise and Release
References
6
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
2
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