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Case Law Database

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

Case No. ADJ9725603
Regular
Nov 23, 2020

LUZ LOZA vs. GOLDBLATT GOLDBLATT/BAY AREA RESTAURANT MANAGEMENT, ARCH INSURANCE COMPANY, administered by YORK RISK SERVICES GROUP, INC.

The Workers' Compensation Appeals Board granted reconsideration of an administrative law judge's order finding the applicant entitled to pre-authorization for their treating physician to issue a PR-4 report at the medical-legal billing rate. While affirming the applicant's right to obtain the report, the Board clarified that the defendant retains the right to object to or raise defenses regarding the physician's billing. The Board reasoned that treating physicians are permitted to provide comprehensive medical-legal evaluations, and such reports are governed by specific medical-legal fee schedules, not the Official Medical Fee Schedule.

PR-4 reportmedical-legal billing ratepre-authorizationprimary treating physician (PTP)Qualified Medical Evaluator (QME)comprehensive medical evaluationOfficial Medical Fee SchedulePetition for ReconsiderationFindings of Fact and Order (F&O)Labor Code
References
3
Case No. ADJ6470549
Regular
Feb 27, 2012

KATHRYN BENSON vs. CITY OF SAN DIEGO

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior decision, allowing a Qualified Medical Examiner's (QME) report into evidence. The original decision excluded the QME report, finding no ratable permanent disability based on the treating physician's opinion. The Appeals Board found the QME report should have been admitted, as there are no explicit time limits for objecting to a treating physician's report or obtaining a QME evaluation for permanent disability. The case is remanded for further proceedings on permanent disability and attorney's fees with the QME report now part of the record.

Workers Compensation Appeals BoardFindings and AwardPetition for ReconsiderationQualified Medical Examiner (QME)Permanent DisabilityFuture Medical TreatmentTreating PhysicianAgreed Medical Examiner (AME)Labor Code Section 4061Strawn v. Golden Eagle Insurance Co.
References
1
Case No. 2021 NY Slip Op 01469
Regular Panel Decision
Mar 11, 2021

Matter of Mayewski v. Superior Plus Energy Servs.

Claimant David Mayewski suffered work-related second and third-degree burns in 2013, leading to scarring and skin grafts. Following a permanency evaluation, his treating physician and an independent medical examiner offered reports concerning a schedule loss of use for his right arm and leg, and the treating physician also found a nonschedule permanent impairment for his torso/skin. The Workers' Compensation Law Judge and the Workers' Compensation Board both concluded that the injuries were amenable to a nonschedule classification. Mayewski appealed this decision, arguing it was limited to his torso and did not account for limited range of motion in his extremities. The Appellate Division, Third Department, affirmed the Board's decision, finding it supported by substantial evidence from the treating physician's report detailing objective skin disorder findings, thermal regulation issues, skin irritation, and intermittent pain.

Workers' CompensationSchedule Loss of UseNonschedule ClassificationPermanent Partial DisabilityBurnsSkin ImpairmentAppellate ReviewMedical EvidenceImpairment Guidelines
References
5
Case No. MISSING
Regular Panel Decision
Feb 21, 2006

Rivera v. Barnhart

Plaintiff Russell Rivera, Jr. challenged the Commissioner of Social Security's decision denying him Supplemental Security Income (SSI) benefits. The case was referred to Magistrate Judge Frank Maas, who issued a Report and Recommendation to remand the action for further administrative proceedings, citing deficiencies in the plaintiff's hearing. After defendant objected to a time limit, an Amended Report and Recommendation was issued, omitting the disputed time limitation. District Judge Richard J. Holwell, finding no clear error, adopted the Amended Report in its entirety, granting the Commissioner’s motion. The court's decision was based on the Administrative Law Judge's failure to fully develop the administrative record and adequately consider the treating physician’s opinion, Dr. Asbury, whose findings differed from a nonexamining medical consultant.

Social Security BenefitsSupplemental Security IncomeDisability DeterminationAdministrative Law Judge (ALJ) ReviewRemand OrderTreating Physician RuleMedical AssessmentHIV/AIDS ImpairmentHepatitis C DiagnosisProcedural Error
References
15
Case No. CV-23-0056
Regular Panel Decision
Dec 14, 2023

In the Matter of the Claim of Daniel Villagil

Claimant Daniel Villagil appealed two decisions from the Workers' Compensation Board. He sustained lower back and left leg injuries from a pot of boiling water in October 2019, leading his treating physician to suggest a 20% schedule loss of use (SLU) award for his left leg. The employer and carrier objected, arguing the scars weren't a basis for SLU. A Workers' Compensation Law Judge denied the award due to the physician's report lacking explanation for the percentage and failing to document permanent physical/functional impairments. The Board affirmed this, finding no credible medical evidence of permanency or functional impairment. Claimant's subsequent application for reconsideration was also denied, prompting these appeals. The Appellate Division affirmed the Board's decision, citing the lack of credible medical proof and the conclusory nature of the treating physician's report, and found no abuse of discretion in denying reconsideration.

Schedule Loss of UsePermanent ImpairmentMedical EvidenceTreating Physician ReportMaximum Medical ImprovementWorkers' Compensation BoardAppellate DivisionReconsideration ApplicationFunctional ImpairmentScars
References
7
Case No. MISSING
Regular Panel Decision

Claim of Quail v. Central New York Psychiatric Center

Claimant appealed a Workers' Compensation Board decision that awarded a 10% schedule loss of use of the right hand. The WCB's decision was based on a September 1998 report from the carrier's consultant, which found a 10% loss. The claimant's treating physician had reportedly found a 20% loss in a July 1998 report, but this report was not properly filed. Despite multiple directives to submit a final medical report from the treating physician, claimant failed to do so before the WCLJ's decision. After the WCLJ's ruling, claimant submitted a newly prepared report from his treating physician indicating a 20% loss. The Board declined to consider this new evidence, citing its discretion to refuse evidence that could have been presented earlier. The appellate court affirmed the Board's decision, finding no abuse of discretion in their refusal to consider the late evidence.

Schedule Loss of UseRight Hand InjuryMedical EvidenceAppellate ReviewBoard DiscretionFailure to Submit EvidenceTreating Physician ReportCarrier Consultant ReportProcedural IssuesPermanency Determination
References
2
Case No. ADJ7117844
Regular
Dec 05, 2011

Tommy Robison vs. CITY OF MARICOPA

The Workers' Compensation Appeals Board denied reconsideration of an award of spinal surgery for Tommy Robison. The employer argued the award was improper because the Spinal Surgery Second Opinion (SSSO) report was untimely and they had implicitly agreed to an Agreed Medical Evaluator's (AME) opinion. The Board found the employer failed to prove a timely objection to the treating physician's recommendation or timely Utilization Review at the hearing. Therefore, the treating physician's recommendation for surgery was controlling, despite the tardiness of the SSSO report, and an AME's opinion did not waive the SSSO process.

Workers' Compensation Appeals BoardPetition for ReconsiderationDeny ReconsiderationSpinal SurgeryAgreed Medical EvaluatorSecond Opinion EvaluatorTimelinessLabor CodeUtilization ReviewTreating Physician
References
5
Case No. MISSING
Regular Panel Decision
Jun 24, 1991

Marziliano v. Sullivan

Plaintiff Josephine Marziliano sought review of a determination by the Secretary of the United States Department of Health and Human Services that denied her request to waive recovery of an overpayment of Supplemental Security Income benefits. The Magistrate Judge recommended that the matter be referred to the Secretary for a new hearing, emphasizing the importance of giving required deference to the treating physician’s opinions in such overpayment waiver proceedings. The defendant objected to the application of the treating physician rule in these proceedings. District Judge Goettel adopted the Magistrate Judge's report and recommendation, affirming that the treating physician rule applies with full force when determining whether a claimant was 'at fault' in accepting an overpayment and ordered the case remanded for a new hearing.

Supplemental Security Income (SSI)Overpayment WaiverTreating Physician RuleMental ImpairmentAdministrative Law Judge (ALJ)RemandSocial Security Administration (SSA)Disability BenefitsResource LimitationsReporting Requirements
References
8
Case No. ADJ1505960 (RDG 0127227)
Regular
Jan 05, 2010

JOSEPH RHOADS vs. WESTERN READY MIX, INC., TRAVELERS PROPERTY \& CASUALTY

The Workers' Compensation Appeals Board rescinded a prior award of spinal surgery, remanding the case for further proceedings. The Board found that the defendant's objection to the treating physician's spinal surgery recommendation failed to follow proper utilization review procedures as outlined in *Cervantes v. El Aguila Food Products, Inc.* The defendant must now adhere to the prescribed utilization review and objection timelines, starting with a new report from the treating physician. The Board expressed no final opinion on the applicant's entitlement to surgery or the attorney's fee pending the WCJ's new decision.

Workers' Compensation Appeals BoardRemovalReconsiderationFindings and AwardWorkers' Compensation JudgeIndustrial InjurySpinal SurgeryTreating PhysicianSecond Opinion PhysicianAmerican College of Occupational and Environmental Medicine Guidelines
References
3
Case No. ADJ6948621 ADJ7946738
Regular
Apr 22, 2013

STEFANO MUSETTI vs. GOLDEN GATE DISPOSAL & RECYCLING dba RECOLOGY, permissibly self-insured, administered by CORVEL CORP.

In this workers' compensation case, the employer sought reconsideration of an award ordering a total knee replacement. The applicant's treating physician recommended the surgery, but the employer argued the award was premature as a panel qualified medical evaluator's report was pending and the treating physician's report lacked proper authorization markings. The Appeals Board denied reconsideration, finding the employer had sufficient time to obtain the PQME report and that the treating physician's report constituted substantial medical evidence supporting the surgery. The Board also noted that the employer failed to initiate utilization review despite being aware of the treatment request.

Workers' Compensation Appeals Boardindustrial injuryright kneegarbage collectortotal knee replacementsupplemental reportpanel qualified medical evaluator (PQME)treating physiciansubstantial medical evidencePetition for Reconsideration
References
7
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