What the panel ordered
The WCAB affirmed the March 2, 2020 Findings of Fact and Orders, holding that defendant did not establish a material change in applicant's condition to justify termination of ongoing home health care. Defendant is obligated to continue providing home health care unless a material change is demonstrated.
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.
The WCJ and WCAB found no persuasive evidence of a material change in applicant's condition to justify termination of ongoing home health care. The treating physician's consistent recommendations and UR certifications supported ongoing medical necessity.
From the decision · page 11In summary, we agree with the WCJ that defendant has not met its affirmative burden of establishing a material change in applicant's medical treatment or circumstance that would otherwise require defendant to either authorize the requested treatment or submit the request to UR. Because there was no valid medical dispute arising out of a change in condition or circumstance, we concur with the WCJ's determination that defendant is obligated to continue to provide treatment in the form of home health care services, unless and until defendant demonstrates a material change in applicant's condition or circumstance.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant failed to prove a material change in applicant's condition to justify termination of home health care.
Favours Applicant prevailed
This failure led to affirmance of ongoing treatment obligation.
From the decision · page 11In summary, we agree with the WCJ that defendant has not met its affirmative burden of establishing a material change in applicant's medical treatment or circumstance that would otherwise require defendant to either authorize the requested treatment or submit the request to UR. Because there was no valid medical dispute arising out of a change in condition or circumstance, we concur with the WCJ's determination that defendant is obligated to continue to provide treatment in the form of home health care services, unless and until defendant demonstrates a material change in applicant's condition or circumstance.
Applicant sustained traumatic brain injury with multiple skull fractures and required decompressive craniectomy surgery.
Favours Applicant prevailed
This established the serious nature of the industrial injury requiring ongoing care.
Treating physician Dr. Yong Lee consistently recommended ongoing home health care throughout 2019.
Favours Applicant prevailed
Supported the finding of ongoing medical necessity for home health care.
From the decision · page 10However, the WCJ also correctly notes that as applicant's treating physician, Dr. Lee continued to update his treatment notes throughout 2019 and identified a consistent array of some 22 medical diagnoses. Dr. Lee recommended continuing provision of multi-modality therapeutic rehabilitation in conjunction with home health aide services throughout 2019. (Report, at p. 4.) The RFAs authored by Dr. Lee on May 23, 2019, August 15, 2019, and September 12, 2019 all review applicant's subjective and objective indicia of progress, and nonetheless reiterate the physician's recommendation for continued, ongoing home health care as part of applicant's comprehensive rehabilitation program. In addition, the May 23, 2019 and August 15, 2019 RFAs
Defendant's UR determinations on May 30, 2019 and August 22, 2019 certified the medical necessity of home health care services.
Favours Applicant prevailed
Provided objective confirmation of ongoing medical necessity.
From the decision · page 8September 27, 2018, at p. 1; Petition, at p. 3:2.) The home health services were subsequently determined to be medically necessary by defendant's UR provider on May 30, 2019. (Ex. H, UR Notice of Determination, dated May 30, 2019, at p. 1.) Therein, the physician reviewer noted that the submitted medical record sufficiently documented applicant's subjective complaints, and that applicant had been reevaluated by neurologist Dr. Wogensen, who concurred with Dr. Lee in the need for ongoing treatment through the TLC and ongoing home health care. The reviewer noted the medical necessity of the request for home health aide services was necessary to "overcome deficits in activities of daily living...." (Id. at p. 7.)
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Dr. Lee consistently recommended ongoing home health care for the applicant's traumatic brain injury and related deficits throughout 2019, supporting the medical necessity of continued treatment.
Dr. Lee's repeated RFAs and treatment notes demonstrated ongoing need for home health care as part of a comprehensive rehabilitation program.
From the decision · page 10However, the WCJ also correctly notes that as applicant's treating physician, Dr. Lee continued to update his treatment notes throughout 2019 and identified a consistent array of some 22 medical diagnoses. Dr. Lee recommended continuing provision of multi-modality therapeutic rehabilitation in conjunction with home health aide services throughout 2019. (Report, at p. 4.) The RFAs authored by Dr. Lee on May 23, 2019, August 15, 2019, and September 12, 2019 all review applicant's subjective and objective indicia of progress, and nonetheless reiterate the physician's recommendation for continued, ongoing home health care as part of applicant's comprehensive rehabilitation program. In addition, the May 23, 2019 and August 15, 2019 RFAs
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4600(a)
An industrially injured worker is entitled to medical treatment reasonably required to cure or relieve the effects of the industrial injury.
The WCAB applied this standard to require defendant to provide ongoing home health care unless a material change in condition is shown.
From the decision · page 6Section 4600(a) provides that an industrially injured worker is entitled, at their employer's expense, to medical treatment that is reasonably required to cure or relieve the effects of the industrial injury. (§ 4600(a).) The coverage of section 4600 extends to any medically related services that are reasonably required to cure or relieve the effects of the industrial injury, even if those services are not specifically enumerated in that section. (Smyers v. Workers' Comp. Appeals Bd. (1984) 157 Cal.App.3d 36, 41 [49 Cal.Comp.Cases 454].)
Patterson v. Workers' Comp. Appeals Bd. (79 Cal.Comp.Cases 910)
An employer may not unilaterally cease authorized treatment without substantial medical evidence of a change in condition.
The WCAB applied Patterson to hold that defendant must show a material change in applicant's condition to terminate ongoing home health care.
From the decision · page 6In Patterson, supra, 79 Cal.Comp.Cases 910, the Appeals Board held that an employer may not unilaterally cease to provide treatment authorized as reasonably required to cure or relieve the effects of industrial injury upon an employee without substantial medical evidence of a change in the employee's circumstances or condition. The panel reasoned:
What proof carried it
The evidence the panel weighed, by kind.
Consistent medical opinions and RFAs from treating physician Dr. Yong Lee supporting ongoing home health care needs.
From the decision · page 10However, the WCJ also correctly notes that as applicant's treating physician, Dr. Lee continued to update his treatment notes throughout 2019 and identified a consistent array of some 22 medical diagnoses. Dr. Lee recommended continuing provision of multi-modality therapeutic rehabilitation in conjunction with home health aide services throughout 2019. (Report, at p. 4.) The RFAs authored by Dr. Lee on May 23, 2019, August 15, 2019, and September 12, 2019 all review applicant's subjective and objective indicia of progress, and nonetheless reiterate the physician's recommendation for continued, ongoing home health care as part of applicant's comprehensive rehabilitation program. In addition, the May 23, 2019 and August 15, 2019 RFAs
UR determinations on May 30, 2019 and August 22, 2019 certifying medical necessity of home health care services.
From the decision · page 8September 27, 2018, at p. 1; Petition, at p. 3:2.) The home health services were subsequently determined to be medically necessary by defendant's UR provider on May 30, 2019. (Ex. H, UR Notice of Determination, dated May 30, 2019, at p. 1.) Therein, the physician reviewer noted that the submitted medical record sufficiently documented applicant's subjective complaints, and that applicant had been reevaluated by neurologist Dr. Wogensen, who concurred with Dr. Lee in the need for ongoing treatment through the TLC and ongoing home health care. The reviewer noted the medical necessity of the request for home health aide services was necessary to "overcome deficits in activities of daily living...." (Id. at p. 7.)
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About this page
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