Independent Medical Review: A New Wave of Litigation in California

Recent noteworthy panel decisions show that the applicant would be wise to present all relevant medical reports and records, and citations to the MTUS, ACOEM, ODG, or other nationally accepted medical standards to the IMR reviewer, and that when a material mistake of fact occurs during the IMR process...

California: A Hint of Things to Come in WCAB's Re-Review of Dubon?

In Garcia-Picen v. Tight Quarters, Inc., the Appeals Board, in a split panel opinion, held that the WCJ incorrectly determined that the defendant’s UR of a treating physician’s request for authorization to provide viscosupplementation injections to treat an applicant’s 3/16/2012 admitted...

Sexual Assault by Co-Worker Not Injury AOE/COE: Cal. Comp. Cases June Advanced Postings (6/25/2014)

Here are the fourth batch of advanced postings for June, and first batch of advanced postings for the July 2014 issue of Cal. Comp. Cases. Lexis.com and Lexis Advance subscribers can link to the case to read the complete headnotes and summaries. © Copyright 2014 LexisNexis. All rights reserved...

California: WCJ Sounds Off on UR/IMR Process - Loynachan v. County of Los Angeles

In Loynachan v. County of Los Angeles , ADJ7144283, the WCJ held that the applicant, who was permanently totally disabled as a result of a 10/1/2009 industrial injury, was entitled to continue receiving 24 sessions of behavioral psychotherapy each year for his mild traumatic brain and cognitive injury...

California: Utilization Review Decision Defective When UR Delay Notice Signed Only by UR Nurse, Not Licensed Physician

In Newton v. Jack-In-The-Box , 2014 Cal. Wrk. Comp. P.D. LEXIS --, a WCAB panel has issued a notice of its intention to award an applicant medical treatment in the form of aquatic therapy twice per week for a period of four weeks, as prescribed by the applicant’s treating physician. The WCAB...

California: MPN Treatment Requests Not Subject to UR/IMR

Karen C. Yotis, Esq., a Feature Resident Columnist for the LexisNexis Workers’ Compensation eNewsletter , provides insights into workplace issues and the nuts and bolts of the workers’ comp world. Is Hogenson Du(ing) an End Run Around Dubon? Is Dubon dead? Well, maybe. Judge Craig Glass...

California: WCAB Imposes Difficult Standards for Overturning a UR Decision

The WCAB, in two recent noteworthy panel decisions, has imposed a difficult standard for applicants seeking to overturn a utilization review (UR) decision. Do these decisions signal a policy decision on the part of the Board to limit reversals of UR decisions? In the first panel decision, the WCAB, in...

California: WCAB Applies Neri Hernandez to Home Health Care Services Cases

The WCAB has issued two noteworthy panel decisions involving home health care services in light of Neri Hernandez (en banc). In each of these decisions, which involved critically injured workers, the WCAB has signaled in very strong terms that it will not tolerate a defendant's bad-faith or frivolous...

California: 2004 Stipulation Regarding Future Medical Treatment Disputes Being Referred to AME Could Not Circumvent UR Procedures

But parties not required to follow new IMR process created by SB 863 as change in law does not supersede parties’ prior stipulation In Bertrand v. County of Orange , 2014 Cal. Wrk. Comp. P.D. LEXIS --, a WCAB panel, granting removal and amending the WCJ’s order, determined that the...

California: Can a Utilization Review Determination Exceed Its Appropriate Scope?

With respect to the increasing litigation over the UR process, is Dubon really the issue in many of these UR disputes? Utilization Review (UR) has been around for more than ten years now. UR first came into play in 2003 when Governor Gray Davis passed Senate Bill 228 . The following year, on April...

California: WCAB Provides Guidance on Addressing Insufficient Utilization Review Documentation

The UR process requires a good faith effort by both the treating physician and the UR physician to assure that the necessary and appropriate information is available In Smith v. Plant Construction , 2014 Cal. Wrk. Comp. P.D. LEXIS –, the WCAB panel rescinded the WCJ’s award of medical...

California: Utilization Review Not Defective When Request for Additional Information Necessary to Make UR Determination Signed by Non-Physician

In a noteworthy panel decision issued August 21, 2014, the WCAB in Newton v. Jack-In-The-Box , 2014 Cal. Wrk. Comp. P.D. LEXIS – , rescinded the WCJ’s award of medical treatment in the form of aquatic therapy after the defendant objected to the WCAB’s 7/7/2014 Notice of Intention to...

California: DIR Director Christine Baker Provides Update on Progress of SB 863 Eighteen Months After Operative Date

A report from the California Workers’ Compensation & Risk Conference, Sept. 10-12, 2014, Dana Point, CA By David Bryan Leonard, Esq. Without pause, Christine Baker, Director of the California Department of Industrial Relations, took the stage immediately following national basketball...

California: WCAB Says MPN Treatment Requests Are Subject to UR/IMR

Legislature did not demonstrate an intent to preclude employers from seeking UR of MPN physicians’ requests for authorization of medical treatment In Stock v. Camarillo State Hospital , 2014 Cal. Wrk. Comp. P.D. LEXIS --, a WCAB panel held that the defendant’s utilization review (UR) determination...

California: W.C.A.B. Issues New, Modified Decision in Dubon

The divided W.C.A.B. has issued its long awaited en banc decision to the defendant’s appeal in Dubon v World Restoration and substantially modified its prior en banc holding to limit the ability of the W.C.A.B. to decide medical issues only in cases where UR is untimely. In doing so the W.C.A.B...

Crocodile Wrestling

At a recent workers’ comp conference in Southern California, WCAB Commissioner Kathy Zalewski noted that the WCAB commissioners had been doing a bit of “crocodile wrestling” over Dubon . I’ve seen crocodile wrestling in Thailand, and it often features a trainer with a stick...

California: When Utilization Review Determination Untimely, No Portion of UR Determination Could Be Relied on to Deny Medical Treatment

WCAB panel issues a new post-Dubon II decision In Korn v. Entertainment Partners , 2014 Cal. Wrk. Comp. P.D. LEXIS --, a WCAB panel affirmed a WCJ’s finding that an applicant, who was employed as a craft services person, suffered an industrial injury to her low back and right shoulder on 5/4...

California: WCAB Affirms Entitlement to Spinal Surgery in a Post-Dubon II Case

In Cabral v. Hal Hays Construction, Inc. , 2014 Cal. Wrk. Comp. P.D. LEXIS --, a WCAB panel, affirming the WCJ, held that an applicant with an industrial injury to his back and neck was entitled to spinal surgery as requested by his treating physician. The WCAB found that the defendant’s 6/9/2014...

California: A Post-Mortem on Dubon

By Rob McCarthy Maurice Abarr wants to set the record straight about what happened leading up to the Dubon II en banc decision earlier this month. He got the chance Saturday at a Van Nuys panel discussion, hosted by Lawworm.com Inc. Maurice is the counsel of record for Jose Dubon, whose back-surgery...

California Workers' Comp Case Roundup (11/1/2014)

CALIFORNIA COMPENSATION CASES Vol. 79 No. 10 October 2014 A Report of En Banc and Significant Panel Decisions of the WCAB and Selected Court Opinions of Related Interest, With a Digest of WCAB Decisions Denied Judicial Review CONTENTS OF THIS ISSUE © Copyright 2014 LexisNexis. All rights...

California Utilization Review: 12-Month Bar to Resubmission of RFA

WCAB finds in the absence of changed circumstances, UR determination was valid for 12 months In Reyes v. Target, Inc., 2014 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB panel affirmed the WCJ’s finding that the applicant, who suffered an admitted industrial injury to her spine, right upper extremity...

California Utilization Review: 24-Hour Extension of Time for Communicating UR Determination

WCAB finds UR untimely and defendant did not communicate UR determination initially by phone, fax or email as required by Rule 9792.9.1(e)(3) In Rivera v. Valley Radiology , 2014 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB panel affirmed the WCJ’s finding that the applicant, who sustained an admitted...

California: Slow Taper of Opioid Usage: UR Decisions Must Be Consistent With the MTUS

In McCool v. Monterey Bay Medicar , 2014 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB panel rescinded the WCJ’s award of medical treatment in the form of Oxycontin, Norco and Lyrica to the applicant who sustained an industrial low back injury on 9/17/83 resulting in three back surgeries. The WCAB...

California: W.C.A.B. Publishes New UR Timeliness Decision

The W.C.A.B. has issued a Significant Panel Decision* reaffirming its language in Dubon v. World Restoration (Dubon II) regarding the W.C.A.B.’s ability to determine medical issues where UR is not completed in a timely fashion and also provided a detailed discussion as to the necessary steps for...

McCool

Can an insurer submit medication prescription requests to utilization review (UR) even where those medications have been repeatedly authorized before? That question has been hotly debated in California workers’ comp circles after a recent WCAB Significant Panel Decision, Patterson v. The Oaks...