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

Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ7048296
En Banc
Apr 20, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America

The Appeals Board held that if an applicant has improperly obtained medical treatment outside the employer’s validly established and properly noticed Medical Provider Network (MPN), the reports of the non-MPN treating physicians are inadmissible and may not be relied upon to award compensation.

MPNnon-MPNinadmissibilitymedical reportstemporary disability indemnityen banc decisionWorkers' Compensation Appeals Boardreconsiderationmedical provider networkself-procured treatment
References
Case No. ADJ7897857
Regular
Feb 29, 2012

ALFONSO PONCE DE LEON vs. BARRETT BUSINESS SERVICES, CORVEL INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a trial judge's order allowing applicant treatment outside the defendant's Medical Provider Network (MPN). The WCAB found the judge improperly investigated the facts himself, violating judicial ethics. The evidence gathered by the judge did not definitively prove MPN non-compliance, and the judge failed to contact all listed physicians. Therefore, the case was returned for a new hearing where parties must present their own evidence regarding MPN physician availability.

MPNMedical Provider NetworkWorkers' Compensation Appeals BoardWCJReconsiderationAccess StandardsRegular PhysicianIndustrial InjuryOrthopedic SpecialistExpedited Hearing
References
Case No. ADJ7048296
Significant
Sep 27, 2011

Elayne Valdez, Applicant vs. Warehouse Demo Services, Zurich North America, Adjusted By ESIS

The Appeals Board affirmed its prior en banc decision, holding that where unauthorized medical treatment is obtained outside a validly established and properly noticed medical provider network (MPN), the resulting non-MPN treatment reports are inadmissible and may not be relied upon to award benefits.

MPNinadmissibilitynon-MPN treatmentLabor Code section 4616.6appeals boardreconsiderationen banc decisionPTPmedical provider networkutilization review
References
Case No. ADJ7048296
Significant
Apr 20, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America, Adjusted by ESIS

The Appeals Board holds that medical reports from unauthorized, non-MPN (medical provider network) physicians are inadmissible and cannot be relied upon to award compensation; consequently, the employer is not liable for the cost of such reports.

MPNnon-MPNadmissibilitymedical provider networkunauthorized treatmentprimary treating physicianen bancWorkers' Compensation Appeals BoardLabor Codetemporary disability
References
Case No. ADJ3002639 (LAO 0881928)
Regular
Jun 11, 2012

MIGUEL NAVA vs. BARRETT BUSINESS SERVICES, INC.

This case concerns an applicant's industrial injury to his spine and knees. The defendant sought reconsideration of a decision that allowed reimbursement for non-MPN providers before November 28, 2008. The Appeals Board granted reconsideration, finding the applicant was bound to select an MPN physician as of his March 11, 2008 deposition stipulation. Therefore, non-MPN services rendered after March 11, 2008, are not compensable.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNBarrett Business ServicesCorVel MPNLien ClaimantIndustrial InjurySpine InjuryKnee InjuryReconsideration
References
Case No. ADJ9884969
Regular
Aug 07, 2015

FERNANDO RUIZ-LUCERO vs. GCA SERVICES GROUP, INC.; ACE AMERICAN INSURANCE COMPANY, administered by ESIS FREMONT

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, upholding the finding that the applicant could treat outside the defendant's Medical Provider Network (MPN). The MPN failed to meet access standards by not having three primary treating chiropractors within a 15-mile or 30-minute radius of the applicant's residence. This failure constitutes good cause for the applicant to seek treatment outside the MPN, as required by regulations ensuring timely access to appropriate medical care. The Board agreed with the WCJ's reasoning that the defendant's inadequate MPN access justified the applicant's out-of-network treatment.

MPNAccess StandardsPrimary Treating PhysicianMedical Provider NetworkChiropractorAdministrative Director RuleWCJReconsiderationLabor CodeSpecialty
References
Case No. ADJ7048296
En Banc
Sep 27, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America

The Appeals Board affirms its prior en banc decision, holding that medical reports obtained from non-MPN physicians are inadmissible for awarding benefits if the treatment was unauthorized and occurred outside a validly established Medical Provider Network (MPN).

Workers' Compensation Appeals BoardEn Banc DecisionMedical Provider Network (MPN)Non-MPN TreatmentInadmissibility of ReportsLabor Code Section 4616.6Primary Treating Physician (PTP)Utilization Review (UR)Qualified Medical Evaluator (QME)Substantive Due Process
References
Case No. ADJ9087890
Regular
Jul 03, 2018

SHERLENE WILLIAMS vs. GOLDEN EMPIRE TRANSIT, RISICO CLAIMS MANAGEMENT

This case concerns a lien claimant's claim for reimbursement following applicant Sherlene Williams' industrial injury as a bus driver. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision denying the lien because the medical provider was not within the defendant's Medical Provider Network (MPN). The majority found the WCJ correctly disallowed the lien due to non-compliance with MPN requirements. A dissenting opinion argued the record was incomplete regarding MPN notice to the applicant and recommended further development of evidence.

Medical Provider NetworkMPNLien ClaimantReconsiderationFindings and OrdersCompromise and ReleaseBurden of ProofMPN NoticeLabor Code Section 4616.3Administrative Director's Rule 9767.12
References
Case No. ADJ7048296
En Banc
Jul 14, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America

The Appeals Board granted reconsideration of its previous en banc decision to further study the legal and factual issues surrounding the admissibility of medical reports from outside a valid MPN.

MPNunauthorized treatmentinadmissible reportsnon-MPN doctorsWCABreconsiderationen bancpetition for reconsiderationsupplemental pleadingopinion and order
References
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