ADJ10393749 · November 18, 2024

The WCAB applied the Patterson doctrine holding that the discontinuation of caregiving services was a termination contrary to Patterson, and that the defendant must prove a change in circumstances to cease services. The petition for reconsideration was denied because no such change was shown.

From the decision · page 13Based on the foregoing, a Findings and Award Re: Medical Treatment was issued on August 9, 2024 and served on interested parties on August 12, 2024. That decision found that the reasoning in the Patterson significant panel decision (Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910), applies to applicant's previously authorized assistance in the home, that the discontinuation of caregiving services in this case was a termination of services contrary to Patterson, that the caregiving services in this case are not subject to the UR process until a change in circumstances showing that the services are no longer reasonably required, and that it is defendant's, not applicant's, burden to prove such a change of circumstances, consistent with Patterson. The decision included an order that defendants reinstate and continue to provide to Ms.

No evidence was presented that there has been a change in the applicant's condition or circumstances that would justify cessation of home healthcare services.

Favours Applicant prevailed

Without such evidence, the defendant cannot meet its burden to prove that caregiving services are no longer reasonably required, supporting the continuation of services.

From the decision · page 18There is no evidence that Dr. Itamura has informed the parties that the applicant no longer needs home healthcare. Accordingly, the evidence and applicable legal considerations support the finding that the Patterson case applies to the applicant's previously authorized assistance in the home, that the discontinuation of caregiving services in this case was a termination of services contrary to Patterson, that the caregiving services in this case are not subject to the UR process until a change in circumstances showing that the services are no longer reasonably required, and that it is defendant's, not applicant's, burden to prove such a change of circumstances, consistent with Patterson, which has not currently been shown in this case. It was therefore within the undersigned's powers and supported by the evidence to order that defendants reinstate and continue to provide to Ms.

the applicant requires home healthcare of eight hours per day until she becomes more independent, supporting the need for ongoing caregiver services.

Dr. Itamura testified that the applicant continues to need home healthcare until she becomes more independent and detailed the activities she needs help with, supporting the continuation of caregiver services.

From the decision · page 9Admitted as Joint Exhibit 12 was the deposition of John Itamura, M.D., dated April 17, 2024. (Id., p. 4, l. 11-12). A summary of salient points made by Dr. Itamura at the deposition are as follows. Dr. Itamura testified that overall, he found the applicant to be a credible person (Id., p. 8, l. 11-12). He performed multiple surgeries on her. The first one was a revision surgery around March 25, 2021, changing out cerclage wire for plastic. The next surgery was another revision, to replace a humeral implant which seemed to be causing an allergic reaction. Unfortunately, the applicant had an allergic reaction to the Dermabond that was used to close the skin after this operation, so a third surgery was performed to remove the skin edges. A fourth surgery was done on January 4, 2024, after two motor vehicle collisions broke the applicant's humerus underneath her prosthesis. Dr. Itamura had to cut all the way down to Ms.

Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910

An employer may not unilaterally cease to provide approved medical treatment services when there is no evidence of a change in the employee's circumstances or condition showing that the services are no longer reasonably required to cure or relieve the injured worker from the effects of the industrial injury.

Applied to the continuation of home caregiving services in this case.

From the decision · page 14The legal question is whether such care may be ceased based upon preordained time limits or inconsistent utilization review without first showing that the care is no longer needed. In the Patterson case, an Appeals Board panel held that (1) the provision of a nurse case manager is a form of medical treatment under Labor Code § 4600, (2) an employer may not unilaterally cease to provide approved nurse case manager services when there is no evidence of a change in the employee's circumstances or condition showing that the services are no longer reasonably required to cure or relieve the injured worker from the effects of the industrial injury, (3) use of an expedited hearing to address the medical treatment issue in this case is expressly authorized by Labor Code§ 5502(b)(l), and (4) it is not necessary for an injured worker to obtain a Request For Authorization (RF A) to challenge the unilateral termination of the services of a nurse case manager. (Patterson, cited supra, 79 Cal. Comp. Cases 910, 911-912.) The reasoning applied to nurse case manager services in Patterson has also been applied to home care services, which also constitute medical treatment. In the case of Warner Brothers v. Workers' Comp. Appeals Bd. (Ferrona) (2015) 80 Cal. Comp. Cases 831, 832-834 (writ denied),

Inconsistent utilization review determinations by different doctors on the reasonableness and necessity of home care services.

From the decision · page 16§ 4600 to cure or relieve the effects of the industrial injury. Following the reasoning in Patterson, it is found that it is defendants' burden to show that the continued provision of the services is no longer reasonably required due to a change in applicant's condition or circumstances. Defendants cannot shift this burden onto applicant by requiring a new RF A to start the UR process over again, reassessing reasonableness and necessity without any change of circumstances. Inconsistency of UR determinations is a risk inherent in the system, but this risk can be avoided by applying the Patterson doctrine. Because each UR determination is written by a different doctor, different results can be obtained on substantially the same record. That is exactly what happened in this case: home care services were certified as reasonable and necessary by UR physician Hark Hsiao. M.D. in Joint Exhibit 5 and Richard Matza, M.D. in Joint Exhibit 6, but non-certified as not reasonable and necessary by Hilary Alpert, M.D. in Joint Exhibit 4 and Chintan Sampat, M.D. in Joint Exhibit 7. This kind of arbitrary inconsistency is not only bad [for] the injured worker's health, but also for the integrity of the whole system.