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

Case No. ADJ3207867
Regular
Apr 21, 2011

JACKIE PLASKETT vs. SAFEWAY INC.

The Workers' Compensation Appeals Board denied Safeway Inc.'s petition for reconsideration of an award for applicant Jackie Plaskett. Safeway argued a Utilization Review (UR) doctor's opinion should have overridden the Agreed Medical Examiner (AME) and primary treating physician's recommendations for aquatherapy. The Board found the UR doctor misapplied treatment guidelines and was internally inconsistent, while the AME's opinion, corroborated by the treating physician, constituted substantial evidence for the necessary treatment. The Board also noted an improperly filed reply brief.

Workers' Compensation Appeals BoardSafeway Inc.Petition for ReconsiderationReport of Workers' Compensation Administrative Law JudgeWCAB Rule 10848Utilization ReviewAgreed Medical ExaminerPrimary Treating PhysicianMedical Treatment Utilization ScheduleMTUS
References
0
Case No. ADJ9145724
Regular
Jun 01, 2015

ARZAGA, JOSE vs. CROWN AUTOMOTIVE, INC., AMTRUST NORTH AMERICA

This case involves an applicant seeking to select a pain management specialist outside his employer's Medical Provider Network (MPN). The applicant argued the MPN failed to provide a qualifying specialist within the required 15-mile/30-minute access standard for a primary treating physician. The Board denied the employer's petition for reconsideration, affirming the applicant's right to choose an out-of-network physician and reimbursement for investigative costs. The majority reasoned that the MPN must meet the closer access standard for a primary treating physician, even if that physician is a specialist. A dissenting opinion argued that a specialist, when chosen as a primary treating physician, should fall under the 30-mile/60-minute access standard for specialists.

Medical Provider NetworkMPNprimary treating physicianpain management specialistaccess standardAdministrative Director's Rule 9767.5investigative costsLabor Code section 5703Lescallett v. Wal-MartMartinez v. New French Bakery
References
2
Case No. ADJ9501859
Regular
May 13, 2015

, Jose Chavez, vs. , Miracle Farms, d/b/a Golden Valley Farms; Star Insurance Company, Administered By Meadowbrook Insurance Group,

The applicant suffered a low back injury and claims additional injuries, with a Physical Medicine and Rehabilitation physician as his primary treating doctor. The WCJ incorrectly ordered a Spine-MNB QME panel, overriding the parties' requests and the primary physician's specialty. The Appeals Board dismissed the applicant's reconsideration petition as untimely for a non-final order. They granted removal, rescinded the WCJ's order, and substituted their own, directing the Medical Unit to issue a QME panel in Physical Medicine and Rehabilitation.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalFindings and OrderQualified Medical EvaluatorQME PanelPhysical Medicine and RehabilitationSpine-MNBOrthopedic PanelPrimary Treating Physician
References
5
Case No. ADJ7925931, ADJ7925917
Regular
Sep 27, 2017

LUISA SEQUEIRA vs. RANDSTAD PLACEMENT PROS, ACE AMERICAN

This case involved an applicant seeking reconsideration of a workers' compensation award, arguing that the declaration of readiness to proceed was defective due to a lack of a primary treating physician's report on permanent disability. The Appeals Board affirmed the original award, finding that Labor Code section 4061(i) does not require all treating physicians to find maximum medical improvement before proceeding to trial. The Board reasoned that the applicant's Panel Qualified Medical Evaluator (PQME) provided substantial medical evidence sufficient to support the permanent disability award, even though primary treating physicians had not yet found MMI. Therefore, the WCJ correctly relied on the PQME's report.

Declaration of readinessPermanent disabilityPrimary treating physicianQualified Medical EvaluatorMaximum medical improvementLabor Code section 4061(i)Substantial medical evidenceFindings Award and OrderReconsiderationIndustrial injury
References
3
Case No. ADJ9549773
Regular
Nov 13, 2015

EDWARD BAUTISTA vs. ARLON GRAPHICS, TRAVELERS

The Appeals Board dismissed the applicant's petition for reconsideration or removal, finding the WCJ's order was not a final determination. The WCJ correctly ordered the applicant to first discuss his anxiety symptoms and need for psychological referral with his primary treating orthopedist. Applicant is not entitled to a second opinion from a psychologist until the primary treating physician has diagnosed the anxiety or determined a referral is unnecessary. Commissioner Sweeney dissented, believing the applicant had an absolute right to an MPN second opinion for his psychiatric condition without first obtaining a referral from his orthopedist.

ADJ9549773Arlon GraphicsTravelersPetition for ReconsiderationPetition for RemovalWorkers' Compensation Appeals BoardWCJLabor Code Section 4616.3Labor Code Section 4616.4Administrative Director Rules
References
4
Case No. ADJ7267845
Regular
Feb 21, 2012

JOSE ACEVEDO vs. TREND PERSONNEL, CHARTIS INSURANCE, GALLAGHER BASSETT SERVICES

This case concerns whether medical liens for treatment rendered after December 18, 2008, are valid. The primary treating physician, Dr. Hoegel, released the applicant from care on that date, and the applicant failed to object to this determination under Labor Code sections 4061 and 4062. Therefore, the applicant could not designate a new primary treating physician and any subsequent treatment liens are barred. The Appeals Board granted reconsideration to clarify that the applicant's failure to follow statutory objection procedures invalidates post-release medical liens.

Workers' Compensation Appeals BoardReconsiderationDecision After ReconsiderationFindings of Facts Re: LiensTenet/Centinela Hospital Medical Center v. Workers' Comp. Appeals Bd. (Rushing)Primary Physician's Permanent and Stationary ReportCompromise and ReleaseLien ClaimantsLabor Code section 4061(b)Labor Code section 4062(a)
References
1
Case No. ADJ9317724
Regular
Jul 23, 2015

JUAN TORRES vs. LINEAGE LOGISTICS COLD STORAGE, TRAVELERS INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the applicant's Petition for Removal. The applicant sought to overturn a Minute Order compelling an orthopedic QME evaluation, arguing the existing orthopedic panel was improperly obtained and preferred a treating doctor. The Board adopted the WCJ's recommendation, finding no substantial prejudice or irreparable harm, as removal is an extraordinary remedy not warranted here. The applicant's preference for a treating doctor did not override the WCJ's order for a QME evaluation requested to clarify a prior medical opinion regarding potential knee surgery.

Petition for RemovalQualified Medical EvaluatorOrthopedic QMEChiropractic QMEKnee SurgeryIndependent Medical OpinionMPNMedical Treatment AuthorizationPrimary Treating PhysicianReconsideration
References
2
Case No. ADJ9724680
Regular
Sep 17, 2018

JAIME RAMIREZ LEON vs. PEOPLEASE/FTU, NATIONAL INTERSTATE INSURANCE

The applicant sought reconsideration of an award denying temporary disability, permanent disability, and further medical care for a right shoulder injury. The applicant argued the primary treating physician's report lacked substantial evidence due to an inadequate history and exam, and the WCJ erred in not relying on the PQME's report. The Appeals Board granted reconsideration to develop the record, specifically regarding whether the primary treating physician reviewed an MRI prior to her report. The original award was rescinded, and the matter was returned for further proceedings and a new decision by the WCJ.

WCABPetition for ReconsiderationFindings of Fact Award and OrderAdministrative Law JudgePrimary Treating PhysicianPQMESubstantial EvidenceMedical ReportInadequate HistoryInadequate Medical Exam
References
12
Case No. ADJ8677592
Regular
Aug 27, 2018

LINDA DAVIES vs. SECURITAS SECURITY SERVICES USA, INC.

This case involves a dispute over reimbursement for medical-legal expenses incurred by a lien claimant, Dr. Kauss, who was designated as the applicant's primary treating physician. The Workers' Compensation Appeals Board (WCAB) rescinded the initial award, finding that the WCJ erred in determining the compensability of Dr. Kauss's reports. The WCAB remanded the case for further proceedings to evaluate compliance with specific statutory requirements regarding objections to medical-legal bills and the distinction between IBR and non-IBR disputes. A dissenting opinion argued Dr. Kauss did not fulfill the duties of a primary treating physician and should not be reimbursed.

Workers' Compensation Appeals BoardReconsiderationMedical-Legal ExpensesPrimary Treating PhysicianLabor Code Section 4060Labor Code Section 4061Lien ClaimantIndependent Bill ReviewExplanation of ReviewDefense Attorney
References
3
Case No. ADJ9052223
Regular
Aug 05, 2016

Joel Rodriguez Luna vs. The Home Depot, Helmsman Management

Here's a summary of the case for a lawyer in a maximum of four sentences: The Workers' Compensation Appeals Board denied Joel Rodriguez Luna's Petition for Removal, affirming the WCJ's finding that Home Depot's Medical Provider Network (MPN) complied with access standards. The WCJ determined that for a specialist, like an orthopedist, the MPN only needed to meet the 30-mile/60-minute access standard, not the stricter 15-mile/30-minute standard for a general primary treating physician. The Board agreed, concluding that since there was at least one orthopedic surgeon within the 30-mile radius, the MPN satisfied its obligations, despite the applicant's preference for a specialist within a closer distance. The dissenting opinion argued the MPN failed by not having at least three specialists readily available to serve as primary treating physicians for the applicant's specific orthopedic injuries.

Workers' Compensation Appeals BoardPetition for RemovalMedical Provider Network (MPN)Access StandardsPrimary Treating PhysicianSpecialistGeographic AreaAdministrative Director's RuleLabor CodeIndustrial Injury
References
3
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