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

Case No. ADJ1313860
Regular
Mar 07, 2017

Kevin Voelker vs. D. Frey Plastering Co., State Compensation Insurance Fund

This case involves a workers' compensation applicant challenging an Independent Medical Review (IMR) determination that denied authorization for shoulder surgery. The applicant argued the IMR incorrectly applied guidelines for acromioplasty/impingement syndrome instead of guidelines for a rotator cuff tear, which was the actual condition for which surgery was requested. The Appeals Board granted reconsideration, finding the IMR's determination was based on a plainly erroneous mistake of fact readily apparent from the submitted records, not requiring expert opinion. Consequently, the Board rescinded the IMR determination and remanded the matter for a new IMR process.

Workers' Compensation Appeals BoardIndependent Medical ReviewPetition for ReconsiderationFindings and OrderPlainly Erroneous Finding of FactMedical Treatment Utilization ScheduleRequest for AuthorizationRotator Cuff TearAcromioplastyImpingement Syndrome
References
Case No. ADJ3149661 (SDO 0271415)
Regular
Apr 27, 2012

Elsa Cervantes vs. COSTCO WHOLESALE CORPORATION, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board granted reconsideration to find that applicant Elsa Cervantes sustained an industrial injury to her left shoulder, overturning the WCJ's prior decision. The Board found substantial medical evidence supported that the rotator cuff tear arose from the April 27, 2000 incident, reversing the WCJ's reliance on Dr. Lane's opinion. Applicant is entitled to further medical treatment, including surgery, and continuing temporary disability benefits for the left shoulder injury. However, the Board affirmed the WCJ's decision regarding the defendant's right to control medical treatment through its Medical Provider Network, finding no contrary evidence of substantiality to overturn the credibility findings.

Workers Compensation Appeals BoardElas CervantesCostco Wholesale CorporationSedgwick Claims Management Servicesindustrial injuryneck injuryleft trapezius muscle injurypsyche injuryleft shoulder injuryMedical Provider Network (MPN)
References
Case No. ADJ306310
Regular
Mar 23, 2009

MATTHEW T. MORAN vs. ABHE & SVOBODA, INC., ZURICH NORTH AMERICA, BRANDVOLD & ASSOCIATES

The Appeals Board granted reconsideration and rescinded the WCJ's March 23, 2009 decision, which awarded further medical treatment including arthroscopic surgery. The Board found the medical record, particularly regarding the conflict between the treating physician's and QME's opinions on the need for surgery and the causation of the left shoulder tear, was not adequately developed. The matter was returned for further proceedings, specifically to obtain an Agreed Medical Evaluator or have the WCJ appoint an expert to resolve the conflicting medical opinions.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardAdministrative Law JudgeQualified Medical EvaluatorIndustrial InjuryLeft ShoulderArthroscopic SurgeryMR ArthrogramRotator Cuff Tear
References
Case No. LAO 854789
Regular
Oct 09, 2007

Juana Manriquez vs. KENVIN, INC., dba CORDOVAN & GREY LTD, STATE COMPENSATION INSURANCE FUND

The applicant sought extended temporary disability benefits, claiming a rotator cuff debridement during shoulder arthroscopy constituted an "amputation" under Labor Code section 4656(c)(2)(C). The Board denied reconsideration, affirming the WCJ's finding that "debridement" of an internal body part, like bone, does not meet the statutory definition of amputation. This definition requires the severance or removal of a limb or body appendage, conforming to the common understanding of the term.

Juana ManriquezKenvin IncState Compensation Insurance FundLAO 854789Petition for ReconsiderationAugust 6 2007 Findings and Ordershoulder arthroscopyamputationLabor Code section 4656(c)(2)(C)temporary disability
References
Case No. ADJ2934117 (STK 0214084)
Regular
Jun 06, 2011

BENNIE MADAVE vs. STOCKTON UNIFIED SCHOOL DISTRICT

This case involves an applicant seeking workers' compensation for a right shoulder rotator cuff repair surgery denied by a WCJ. The WCJ ruled the need for surgery stemmed from a subsequent non-industrial accident, not the initial industrial injury. The Appeals Board granted reconsideration, rescinded the original order, and returned the case for further medical record development. This is because the medical evidence failed to definitively determine if the surgery was necessary to cure or relieve the effects of the industrial injury, even if the tear itself wasn't solely industrially caused.

Rotator cuff repairIndustrial injuryNon-industrial accidentUtilization reviewPanel Qualified Medical EvaluatorPQMEApportionmentPermanent disabilityInextricably linkedFurther development of medical record
References
Case No. ADJ383777
Regular
Apr 04, 2011

Roxanna Ortiz vs. ONE SOURCE, ESIS

The Workers' Compensation Appeals Board denied Roxanna Ortiz's petition for reconsideration of a prior findings and order. The initial ruling determined she sustained industrial injury only to her cervical spine as a janitor, not to other body parts or any resulting temporary/permanent disability or need for further medical treatment. Ortiz argued the judge erred by favoring defense medical reports and discrediting her testimony due to minor inconsistencies in her injury description. The Board adopted the WCJ's report, emphasizing deference to credibility determinations and that admissibility of medical reports should have been challenged at trial, not on reconsideration. A dissenting opinion argued the judge overemphasized minor variations in Ortiz's account and that medical evidence did not sufficiently support denial of other injuries or further treatment.

OrtizOne SourceESISWCABFindings and OrderPetition for ReconsiderationWorkers' Compensation Administrative Law Judgeindustrial injurycervical spineright arm
References
Case No. ADJ 0101021, ADJ 0101756, AHM 0101021, AHM 0101756
Regular
Aug 20, 2008

Mario Nunez vs. MERIT ELECTRIC, INC., INDEMNITY INSURANCE COMPANY OF NORTH AMERICA, GALLAGHER BASSETT SERVICES, INC.

Reconsideration granted due to insufficient medical evidence regarding temporary disability between 12/27/2007-4/8/2008. Case returned for further proceedings.

Temporary disabilityPermanent and stationary dateAgreed Medical Examiner (AME)ReconsiderationJoint Findings of FactMedical treatment authorizationSurgeryRight shoulder re-tearRotator cuffMedical evidence deficiency
References
Case No. ADJ7307162 ADJ7307160
Regular
Mar 07, 2012

MIRNA SAMAYOA vs. METHODIST HOSPITAL, Permissibly Self-Insured, Adjusted By INTERCARE HOLDINGS INSURANCE SERVICES, INC.

Defendant Methodist Hospital sought removal from a WCJ order taking the case off calendar to allow the applicant further medical discovery. The Appeals Board granted removal, finding the WCJ erred by accepting the applicant's vague objection to the defendant's Declaration of Readiness to Proceed. The Board rescinded the off-calendar order, deeming further discovery unwarranted after an Agreed Medical Examiner had provided findings on all disputed medical issues. The case was returned to the WCJ to set a Mandatory Settlement Conference based on the defendant's DOR.

Workers' Compensation Appeals BoardRemovalMandatory Settlement ConferenceDeclaration of Readiness to ProceedAgreed Medical ExaminerPanel QMEUtilization ReviewPermanent and StationarySpecific InjuryCumulative Trauma
References
Case No. ADJ7516947
Regular
Jul 19, 2011

LAWRENCE SHANTELER vs. GATEWAY LIQUOR, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration of a decision awarding benefits to Lawrence Shanteler. Petitioners Gateway Liquor and State Compensation Insurance Fund argued the administrative law judge erred in finding the injury arose out of and occurred in the course of employment and raised a post-termination claim issue. The Board adopted the WCJ's report, emphasizing the significant weight given to the WCJ's credibility findings. The WCJ found Shanteler's testimony credible regarding the injury and his attempts to report it, discrediting contrary employer testimony and surveillance video evidence.

AOE/COEPetition for ReconsiderationWCALJCredibilitySubstantial EvidenceAuthenticationChain of CustodyPost-Termination ClaimDVR RecordingsIndustrial Injury
References
Case No. ADJ11836757
Regular
Sep 09, 2019

Greg Joshua vs. Legend Transportation, National Interstate Insurance

The Workers' Compensation Appeals Board granted reconsideration to defer the issue of Labor Code section 5814 penalties, finding the administrative law judge's initial award premature. The Board determined that Dr. Schmidt's reports constituted substantial medical evidence regarding the applicant's temporary total disability for his left shoulder injury, despite the defendant's arguments about incomplete medical history. However, the Board found that section 5814 penalties are not appropriate for expedited hearings and must be addressed separately. The case is returned to the WCJ for further proceedings specifically on the section 5814 penalty issue.

ADJ11836757AOE/COEPetition for ReconsiderationFindings and AwardTemporary Disability IndemnityLabor Code Section 5814Substantial Medical EvidencePrimary Treating PhysicianDr. SchmidtCredibility
References
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