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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. ADJ7532885
Regular
Aug 01, 2016

DAVID AREVALO vs. THE MILLARD GROUP, AIG/NATIONAL UNION FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the employer's petition for reconsideration, rescinding prior findings. The Board found the initial decision lacked substantial evidence and failed to address crucial issues like the MPN's validity and the employer's loss of medical control. The case is returned to the trial level for further proceedings to determine these issues and whether the employer refused, delayed, or denied medical treatment. The initial finding of denied treatment was based on insufficient evidence to establish liability for self-procured treatment.

MPNMedical Provider NetworkRefusal of TreatmentDelay of TreatmentDenial of TreatmentLoss of Medical ControlPanel Qualified Medical ExaminerPQMELien ClaimantsPrimary Treating Physician
References
Case No. ANA 0378959
Regular
May 27, 2000

MAI HO vs. MARRIOTT INTERNATIONAL

The Appeals Board granted reconsideration to reverse a restitution order against chiropractor Vu Phan, D.C., who provided unauthorized treatment. While Phan is not entitled to further payment for treatment not authorized by the employer, the Board found that the employer voluntarily paid $6,500 for past treatment and thus cannot recover it absent fraud, thus denying the employer's restitution claim. The Board otherwise affirmed the original decision denying Phan's lien claim for the unauthorized treatment.

Workers' Compensation Appeals BoardLien claimantRestitutionOverpaymentMedical treatmentUnauthorized treatmentPrimary treating physicianSelf-procured treatmentUnjust enrichmentVoluntary payment
References
Case No. ADJ1524412 (RDG 0043469)
Regular
Oct 18, 2011

STEPHEN FLESHMAN vs. MANDINA'S CUSTOM CABINETS, STATE COMPENSATION INSURANCE FUND

This case involves a dispute over ongoing chiropractic treatment for a back injury sustained in 1989. The defendant sought reconsideration of a prior award granting weekly chiropractic visits, arguing the treatment wasn't providing functional restoration after 21 years. The Appeals Board affirmed the award of 90 days of weekly chiropractic treatment, finding it supported by the treating chiropractor's reports and testimony. However, the Board amended the order to require further medical evaluation after the 90 days to determine future treatment needs.

Workers' Compensation Appeals BoardIndustrial InjuryBack and SpineStipulated AwardPermanent DisabilityFurther Medical TreatmentChiropractic TreatmentChronic Pain Medical Treatment GuidelinesFunctional RestorationProgress Report
References
Case No. ADJ4028210 (SJO 0251585)
Regular
Apr 06, 2009

JENNY PHAM vs. SANMINA-SCI CORPORATION, SENTRY CLAIMS SERVICE

This case concerns a dispute over the reasonableness and necessity of chiropractic and acupuncture treatment provided to an applicant for an industrial injury. The defendant argues the treatment exceeded the ACOEM Guidelines and was not evidence-based. The Appeals Board granted reconsideration, finding the WCJ's prior decision allowing the lien premature. The Board rescinded the decision and returned the case for further development of the medical record to determine if the treatment complied with the ACOEM Guidelines. The defendant's petition for removal was dismissed as moot.

Petition for RemovalPetition for ReconsiderationFindings and OrderCompromise and ReleaseIndustrial InjuryNeck InjuryBilateral ShouldersReasonable and Necessary TreatmentACOEM GuidelinesLabor Code Section 4600
References
Case No. ADJ9957492 ADJ9957588 ADJ10160287
Regular
Jul 14, 2017

JULIO NUNEZ vs. BARRETT BUSINESS SERVICES, INC., ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a petition for reconsideration by Barrett Business Services, Inc. and Ace American Insurance Company. The defendants sought to overturn a finding that the applicant, Julio Nunez, was entitled to choose his own psychotherapy provider due to a delay in treatment authorization. The Board agreed with the WCJ that the defendant's failure to authorize treatment with a chosen MPN provider after receiving proper notification established the applicant's right to seek care outside the MPN. This entitlement arose from specific instances of delayed and denied authorization for psychotherapy.

Workers' Compensation Appeals BoardReconsiderationJoint Findings and OrderPsychotherapy treatmentMedical Provider NetworkMPNProvider of choiceAuthorizationDelay of treatmentDenial of treatment
References
Case No. ADJ8234651 MF ADJ8234652
Regular
Sep 12, 2014

ZULEMA MIRANDA vs. ARAMARK, permissibly self-insured

The Workers' Compensation Appeals Board granted reconsideration and reversed the Administrative Law Judge's (ALJ) order compelling the employer to authorize out-of-network shoulder surgery. The Board found insufficient evidence that the employer denied, refused, or neglected to provide reasonable treatment for the applicant's left shoulder within its Medical Provider Network (MPN). Therefore, the employer is not liable for the self-procured treatment sought by the applicant outside the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNUtilization ReviewURAgreed Medical EvaluatorAMECumulative InjurySpecific InjuryPetition for Reconsideration
References
Case No. ADJ9791003
Regular
Feb 21, 2020

FRANKLIN LOPEZ DE LA CRUZ vs. BARRETT BUSINESS SERVICES, INC.

This case concerns a lien claimant, Optimal Health, seeking reimbursement for medical treatment provided to an applicant injured on July 1, 2014. The applicant's employer accepted a lumbar spine injury but denied claims for thoracic spine, cervical spine, and leg injuries. The initial WCJ disallowed Optimal Health's lien, ruling treatment outside the approved Medical Provider Network (MPN) was improper. The Appeals Board granted reconsideration, finding the applicant may self-procure treatment for denied body parts. The Board remanded the case for further proceedings to determine if the applicant sustained injury to denied body parts, if treatment was reasonable and necessary, and if fees were appropriate.

Medical Provider NetworkMPNdenied body partsself-procured treatmentlien claimantburden of proofindustrial injuryreasonable and necessary treatmentMedical Treatment Utilization ScheduleMTUS
References
Case No. ADJ2401554 (FRE 023126)
Regular
Jan 07, 2013

JOSHUA GROSSMAN vs. ARAMARK UNIFORM SERVICE, ACE AMERICAN INSURANCE COMPANY

The Appeals Board granted reconsideration, reversing the judge's decision and finding the defendant liable for self-procured medical treatment. The defendant failed to prove they properly transferred the applicant into their Medical Provider Network (MPN) and neglected or refused to provide reasonable treatment by failing to ensure MPN physician availability. Consequently, the applicant's self-procured treatment from the lien claimant is deemed reasonable and compensable. The defendant is liable for the reasonable cost of this treatment, plus interest and penalties.

MPNself-procured medical treatmentneglect or refusal to provide medical treatmentprimary treating physicianlien claimantreasonable medical treatmentAramark Uniform ServiceAce American Insurance CompanySan Joaquin Accident & Medical GroupKnight v. Liberty Mut. Ins. Co.
References
Case No. SAL 87190
Regular
Jul 12, 2007

PATRICIA A. ORTIZ vs. SALINAS UNION HIGH SCHOOL DISTRICT

The Workers' Compensation Appeals Board granted reconsideration to affirm an award for applicant's self-procured medical treatment, holding the employer liable as treatment need stemmed at least partially from the admitted industrial injury. The Board also deferred the issue of attorneys' fees under Labor Code section 4607 pending Supreme Court decisions, and returned the case to the trial level to further develop the record regarding new and further permanent disability. The WCJ's deferral of the new and further disability issue was deemed proper due to insufficient evidence presented by either party.

Self-procured medical treatmentNew and further permanent disabilityPetition to reopenSubstantial evidenceQualified Medical EvaluatorAttorneys' feesLabor Code section 4607ReconsiderationWorkers' Compensation Appeals BoardIndustrial injury
References
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