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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
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 The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr.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. ADJ2904305 (GOL 0095697) ADJ1827151 (GOL 0095698)
Regular
Aug 02, 2010

GUADALUPE CARRILLO vs. SAN ANTONIO VILLAGE HOA, STATE FARM INSURANCE COMPANIES

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration regarding a disallowed lien balance of $9,349.46. The claimant, a doctor, failed to obtain required written authorization for work hardening services billed under CPT Code 97545. Despite a claim of verbal authorization and a general request for multiple modalities, the Board found the lack of specific written authorization for the disputed services to be determinative. Therefore, the administrative law judge's disallowance of the lien balance was upheld.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationCompromise and ReleaseWork hardeningWork conditioningCPT Code 97545Prior authorizationVerbal authorizationWritten authorization
References
Case No. ADJ6909910
Regular
Aug 01, 2017

GILBERTO MORALES vs. HERRICK CORP.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and reversed a prior ruling regarding an epidural steroid injection (ESI). The WCAB found that the defendant's initial authorization for an ESI at the C6-C7 level was not superseded by a subsequent request for a more extensive ESI by a new treating physician. The Board determined there was no documented change in the applicant's medical condition to justify further utilization review of the previously authorized C6-C7 ESI. Therefore, the defendant remains obligated to provide the C6-C7 ESI without additional utilization review.

Epidural Steroid InjectionUtilization ReviewPrior AuthorizationChange of PhysicianCervical SpineWCABPetition for ReconsiderationIndependent Medical ReviewPrimary Treating PhysicianRequest for Authorization
References
Case No. MON 0325089 MON 0325090
Regular
Oct 05, 2007

NORA MEDEARIS vs. COUNTY OF LOS ANGELES

This case concerns the denial of an applicant's petition for reconsideration of a workers' compensation award. The applicant sought further temporary disability benefits beyond the 104-week limit imposed by Labor Code § 4656(c)(1). The Workers' Compensation Appeals Board denied the petition, finding the applicant failed to prove equitable estoppel against the defendant's application of the statutory limit, despite the defendant's initial refusal to authorize shoulder surgery. The Board adopted the WCJ's reasoning that the applicant did not demonstrate reliance on any conduct by the defendant that prevented her from timely pursuing authorization for the surgery.

Workers' Compensation Appeals BoardNora MedearisCounty of Los AngelesPermissibly Self-InsuredMON 0325089MON 0325090Opinion and Order Denying Petition for ReconsiderationInterim Joint Findings and AwardCentral Services TechnicianIndustrial Injury
References
Case No. ADJ10896105
Regular
Mar 22, 2018

MICHAEL GHATTAS vs. O'REILLY AUTO PARTS, SAFETY NATIONAL CASUALTY COMPANY

This case concerns whether an employer must authorize requested medical treatment for a denied workers' compensation claim. The Appeals Board denied the applicant's petition for reconsideration, upholding its prior decision. The Board concluded that the employer's timely denial of the claim under Labor Code section 5402 terminated their responsibility to authorize medical treatment. Therefore, the employer was not obligated to submit the physician's request for authorization (RFA) to utilization review despite it being pending when the denial was issued.

Workers' Compensation Appeals BoardPetition for ReconsiderationOpinion and Order DenyingDecision After ReconsiderationFindings of Fact Award and OrderRequest for AuthorizationUtilization ReviewLabor Code Section 5402Claim DenialMedical Treatment Authorization
References
Case No. ADJ7735518 ADJ7735519 ADJ7735513 ADJ7735501 ADJ7735502 ADJ7736429 ADJ7736449 ADJ7735498 ADJ7098593 ADJ7735514
Regular
Jul 29, 2014

Marialaine Tabak vs. SAN DIEGO UNIFIED SCHOOL DISTRICT

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration regarding a dispute over medical treatment authorization. The core issue was whether a Medical Provider Network (MPN) could restrict treatment to specific office locations of a listed physician. The Board affirmed the WCJ's finding that the defendant school district properly denied authorization for treatment at an unauthorized location of an MPN physician. The MPN's explicit listing stated providers were in-network only at designated locations, and this contractual limitation was upheld. Therefore, treatment outside the approved location was at the applicant's own expense.

Medical Provider NetworkMPNPhysician locationAuthorizationSelf-procureGeographic limitExclusive rightContractual limitationsEmployer's obligationAdministrative Director's Rule
References
Case No. ADJ7410410
Regular
Oct 29, 2014

MARTHA REYES vs. TARGET, INC.

The Workers' Compensation Appeals Board denied Martha Reyes' petition for reconsideration. While a utilization review (UR) decision should be signed, failure to do so does not invalidate it, per *Dubon II*. The applicant's recourse was to request Independent Medical Review (IMR), which she did. Therefore, the prior UR decision remained valid for 12 months, rendering the timeliness of the employer's denial of a subsequent request for authorization immaterial.

Utilization ReviewIndependent Medical ReviewDubon IILabor Code Section 4610Request for AuthorizationTimelinessPetition for ReconsiderationWCABEn Banc DecisionClaims Administrator
References
Case No. ADJ1291435
Regular
May 17, 2010

JUAN ANTONIO PEREZ GARCIA vs. TAPIA BROTHERS, STATE COMPENSATION INSURANCE FUND

This case involves a workers' compensation applicant who sustained admitted industrial injuries to his neck, shoulder, and knee. The defendant sought reconsideration, arguing the WCJ erred in not apportioning the permanent disability due to a prior injury settlement. The Appeals Board granted reconsideration, finding the prior compromise and release constituted a prior permanent disability award, requiring an apportionment analysis. The Board rescinded the WCJ's decision and returned the case for further proceedings to determine permanent disability and apportionment based on overlap principles.

ApportionmentCompromise and ReleasePermanent DisabilityOverlap PrinciplesPrior AwardWCJReconsiderationLabor Code § 4664Labor Code § 4663Disability Factors
References
Case No. ADJ8484771
Regular
Nov 14, 2014

MIKE REIS vs. SILVAS OIL COMPANY, EMPLOYERS INSURANCE OF WAUSAU

The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration, reversing a prior decision that had found carpal tunnel surgery authorized. The Board determined that a letter from defendant's attorney did not authorize the surgery, and the subsequent utilization review (UR) was timely and not procedurally defective. As the UR was timely, any challenges to its validity must go through Independent Medical Review (IMR), which had previously determined the surgery was not medically supported. Therefore, the prior award granting the surgery was rescinded.

Workers' Compensation Appeals BoardPetition for ReconsiderationAmended OpinionSilvas Oil CompanyEmployers Insurance of WausauUtilization ReviewAgreed Medical EvaluatorCarpal Tunnel SurgeryRequest for AuthorizationIndependent Medical Review
References
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