ADJ11422165 — California WCAB decision

What the panel ordered

Affirmed the December 28, 2021 Amended Findings and Award except amended Finding of Fact No. 8 to reflect possible future medical treatment need.

Petition for Reconsideration of the December 28, 2021 Amended Findings and Award granted to study legal and factual issues; now decision after reconsideration issued affirming the F&A except amending Finding of Fact No. 8 regarding future medical treatment.

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What was disputed, and how it came out

Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.

Medical treatment / UR / IMRApplicant prevailedneck

The QME's opinion indicated possible need for future medical treatment, and the Board concluded the applicant's right to future medical treatment should not be foreclosed, amending the Finding of Fact accordingly.

From the decision · page 5Here, the QME's analysis has focused largely on the question of the efficacy of applicant's current treatment regimen, rather than substantively evaluating whether applicant's industrial injuries may require medical treatment in the future. It is not clear from the current record that the QME fully appreciated the scope of the potential entitlement to future medical treatment afforded under section 4600(a). However, to the extent that the QME has endorsed the potential need for both medications and instruction from a qualified physical therapist, we conclude that applicant's right to possible future medical treatment under section 4600(a) should not be foreclosed. Accordingly, we will amend Finding of Fact No. 8 to reflect that applicant may require future medical treatment to cure or relieve from the effects of his industrial condition. We again observe that any dispute regarding the medical necessity of a requested treatment modality will be subject to the prescribed utilization review and the independent medical review processes. (Lab. Code, § 4610; 4610.5; 4610.6.)

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

QME Dr. Ramsey opined no current need for further medical intervention but endorsed possible future medications and physical therapy.

Favours Applicant prevailed

Supported the Board's amendment to Finding of Fact No. 8 to allow for future medical treatment rights.

From the decision · page 5Here, the QME's analysis has focused largely on the question of the efficacy of applicant's current treatment regimen, rather than substantively evaluating whether applicant's industrial injuries may require medical treatment in the future. It is not clear from the current record that the QME fully appreciated the scope of the potential entitlement to future medical treatment afforded under section 4600(a). However, to the extent that the QME has endorsed the potential need for both medications and instruction from a qualified physical therapist, we conclude that applicant's right to possible future medical treatment under section 4600(a) should not be foreclosed. Accordingly, we will amend Finding of Fact No. 8 to reflect that applicant may require future medical treatment to cure or relieve from the effects of his industrial condition. We again observe that any dispute regarding the medical necessity of a requested treatment modality will be subject to the prescribed utilization review and the independent medical review processes. (Lab. Code, § 4610; 4610.5; 4610.6.)

Applicant wore a Kevlar safety vest but did not have arresting power or sworn duties; could call law enforcement if unsafe.

Favours Defendant prevailed

Supported the Board's affirmation of occupational group number 251 rather than 390.

From the decision · page 5Applicant further challenges the WCJ's determination of the occupational group number, contending that because he used a Kevlar safety vest, "[t]he fact that there were safety risks and concerns that would require the wearing of body armor as an essential part of the applicant's employment supports the Applicant's contention that Occupation Group 390 is accurate in this case and the injured worker should be given that classification." (Petition, at p. 3:5.) However, we concur with the WCJ's observation that applicant was not required to perform the duties traditionally associated with safety officers but could always retreat or leave if he felt unsafe and could call law enforcement as needed. (Report, at p. 3.) We agree with the WCJ's conclusion that applicant's job duties were appropriately classified as falling within Group 251. We therefore decline to disturb the WCJ's findings in this regard.

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code section 4600(a)

Labor Code section 4600(a) requires employer to provide medical treatment reasonably required to cure or relieve effects of industrial injury throughout employee's life unless resolved by parties.

Applied to determine entitlement to future medical treatment.

From the decision · page 4In a larger context, however, we are mindful that pursuant to section 4600(a), the employer is required to provide medical treatment "reasonably required to cure or relieve the injured work from the effects of the worker's injuries." (Lab. Code, § 4600(a).) This requirement to provide medical treatment for a workplace injury continues throughout the entire life of the employee unless the parties specifically resolve the issue of medical treatment. (United States Fidelity & Guaranty Co. v. Dept. of Ind. Relations (1929) 207 Cal. 144; Ferguson v. Workers' Comp. Appeals Bd. (1995) 33 Cal.App.4th 1613, fn. 12; Lab. Code, § 3209.5 [medical treatment]; Lab. Code, § 5000, 5001, 5702 [settlement by way of a compromise and release or stipulation].) As a result, an employer may still be providing medical treatment to an industrially injured worker long after they have left employment.

Labor Code sections 4610, 4610.5, 4610.6

Labor Code sections 4610, 4610.5, 4610.6 describe utilization review and independent medical review processes for medical treatment disputes.

Referenced as procedural safeguards for future medical treatment disputes.

From the decision · page 4therapy and medication, standing alone, is a sufficient basis for the provision of future medical treatment. (See, e.g., Argonaut Insurance Co. v. Workers' Comp. Appeals Bd. (Garcia) (1996) 61 Cal.Comp.Cases 378 (writ den.); County of Los Angeles v. Workers' Comp. Appeals Bd. (Garcia) (1995) 60 Cal.Comp.Cases 617 (writ den.).) We further observe that the medical necessity of any such request for future medical treatment would be subject to the utilization review and independent medical review processes described in Labor Code2 sections 4610 and 4610.5.

Administrative Director Rule 35.5(g)(2)

Administrative Director Rule 35.5(g)(2) requires QME to opine on need for future medical care to cure or relieve effects of industrial injury.

Guided QME's opinion on future medical treatment entitlement.

From the decision · page 4Thus, while any future request for medical treatment pursuant to section 4600(a) would be subject to evaluation for medical necessity through the utilization review process, the underlying determination of entitlement to seek that future medical treatment must contemplate whether the need for treatment may arise over the course of the injured worker's lifetime. We further observe that per Administrative Director Rule 35.5, subd. (g)(2), the QME "shall not provide an opinion on any disputed medical treatment issue, but shall provide an opinion about whether the injured worker will need future medical care to cure or relieve the effects of an industrial injury." (Cal. Code Regs., tit. 8, § 35.5(g)(2).)

ADJ11422165 · February 24, 2026

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

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The rules the panel named

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