ADJ11686539 — California WCAB decision

ADJ11686539 · February 21, 2025

Reconsideration granted; WCJ's decision rescinded; new findings issued establishing injury AOE/COE to right wrist, shoulder, and arm; all other issues including value and timeliness of lien deferred; matter returned to trial level for further proceedings.

Issues decided

Medical opinions weighed

Authorities named

District office

Oxnard

What the panel ordered

Lien claimant Optimal Health Medical Center sought reconsideration of the WCJ's Findings and Order disallowing its lien for failure to prove industrial injury. The WCAB granted reconsideration, rescinded the F&O, and substituted new findings establishing injury AOE/COE to the right wrist, shoulder, and arm, deferring other issues.

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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.

AOE/COEApplicant prevailedright wrist · right shoulder · right arm

The WCAB found the reporting of the QME was not substantial evidence due to lack of accurate history and analysis, but the PTP Dr. Shen's reports provided a reasonable medical and vocational history, competent examination, and analysis supporting industrial causation, thus establishing injury AOE/COE.

From the decision · page 6Thus, and based on the reporting of PTP Dr. Shen, we are persuaded that lien claimant has sustained its burden of establishing injury AOE/COE to the right shoulder, arm, and wrist.

The facts that decided it

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

PTP Dr. Shen's reports provided a detailed and accurate medical and vocational history, competent examination, and analysis supporting industrial causation.

Favours Applicant prevailed

The WCAB found these reports constituted substantial medical evidence establishing injury AOE/COE, meeting the lien claimant's burden.

From the decision · page 6The medical reporting of applicant's PTP thus contains a reasonable medical and vocational history that acknowledges the claimed injury, reviews applicant's job duties and daily exertional levels, accomplishes a competent physical examination, and analyzes the relationship between applicant's work exposures and the established medical diagnoses. Because the medical opinions of the PTP are framed in terms of reasonable medical probability, are based on an accurate history and an examination, and set forth reasoning to support the expert conclusions reached, the reporting of Dr. Shen constitutes substantial medical evidence establishing injury AOE/COE. (Gatten, supra, 145 Cal.App.4th 922, 928; Escobedo, supra, 70 Cal.Comp.Cases 604.)

QME Warren's report lacked an appropriate review of history, was internally inconsistent, and did not analyze the relationship between work exposures and injuries.

Favours Applicant prevailed

The WCAB rejected the QME's report as not substantial evidence, so it did not rebut the PTP's opinion.

From the decision · page 59.) The QME's analysis of causation is limited to a single sentence that "cooks do not get lung cancer by leaning over a stove." (Ibid.) The QME cites to no medical evidence in support of his conclusions, reviews no medical literature addressing applicant's contentions, and offers no substantive discussion that reflects an understanding of the scope of the injury alleged, or an analysis of the relationship between applicant's work exposures and his alleged injuries. Because the QME's reporting does not reflect a reasonable understanding of the medical issues alleged or an accurate medical and vocational history, and because the report discloses no substantive analysis of the medical issues presented, we conclude that the QME reporting does not rise to the level of substantial evidence.

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.

PTPRelied upon

Dr. Shen provided a reasonable medical and vocational history, competent physical examination, and analysis supporting that applicant sustained industrial cumulative trauma to the right shoulder, arm, and wrist, consistent with his job duties.

The WCAB credited Dr. Shen's reports as substantial medical evidence establishing injury AOE/COE.

From the decision · page 6The medical reporting of applicant's PTP thus contains a reasonable medical and vocational history that acknowledges the claimed injury, reviews applicant's job duties and daily exertional levels, accomplishes a competent physical examination, and analyzes the relationship between applicant's work exposures and the established medical diagnoses. Because the medical opinions of the PTP are framed in terms of reasonable medical probability, are based on an accurate history and an examination, and set forth reasoning to support the expert conclusions reached, the reporting of Dr. Shen constitutes substantial medical evidence establishing injury AOE/COE. (Gatten, supra, 145 Cal.App.4th 922, 928; Escobedo, supra, 70 Cal.Comp.Cases 604.)

QMERejected

QME Warren found no industrial injury, but his report lacked an appropriate review of medical and vocational history, was internally inconsistent, and did not provide substantial evidence.

The WCAB found the QME's report did not rise to the level of substantial evidence due to lack of analysis and accurate history.

From the decision · page 59.) The QME's analysis of causation is limited to a single sentence that "cooks do not get lung cancer by leaning over a stove." (Ibid.) The QME cites to no medical evidence in support of his conclusions, reviews no medical literature addressing applicant's contentions, and offers no substantive discussion that reflects an understanding of the scope of the injury alleged, or an analysis of the relationship between applicant's work exposures and his alleged injuries. Because the QME's reporting does not reflect a reasonable understanding of the medical issues alleged or an accurate medical and vocational history, and because the report discloses no substantive analysis of the medical issues presented, we conclude that the QME reporting does not rise to the level of substantial evidence.

The rules the panel named

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

Lab. Code §§ 4600(a), 4903(b), 5705, 3202.5; Kunz v. Patterson Floor Coverings (2002) 67 Cal.Comp.Cases 1588 (en banc); Kaiser Foundation Hospitals v. WCAB (Martin) (1985) 39 Cal.3d 57; Zenith Insurance Co. v. WCAB (Capi) (2006) 138 Cal.App.4th 373; Tapia v. Skill Master Staffing (2008) 73 Cal.Comp.Cases 1338 (en banc)

A lien claimant must establish industrial injury by a preponderance of the evidence and prove all elements necessary to validate its lien, including that treatment was reasonably required to cure or relieve the effects of injury.

The WCAB applied these standards to find that the lien claimant met its burden of proof for injury AOE/COE based on substantial medical evidence from the PTP.

From the decision · page 4II. Generally, a lien for medical treatment is allowable when the treatment rendered is reasonably required to cure or relieve an injured worker from the effects of an industrial injury (Lab. Code, § 4600(a), 4903(b)) but a defendant will not be liable for medical treatment where there is no industrial injury. (Kunz v. Patterson Floor Coverings (2002) 67 Cal.Comp.Cases 1588, 1593 (Appeals Board en banc).) Therefore, where a lien claimant, rather than the injured worker, litigates the issue of entitlement to payment for industrially-related medical treatment, the lien claimant stands in the shoes of the injured worker and it must establish industrial injury by a preponderance of evidence. (Kaiser Foundation Hospitals v. Workers' Comp. Appeals Bd. (Martin) (1985) 39 Cal.3d 57, 67 [50 Cal.Comp.Cases 411]; Kunz, supra, 67 Cal.Comp.Cases at p. 1592.) In addition, a lien claimant has the burden of proving all the elements necessary to establish the validity of its lien. This includes the burden of showing that the treatment it provided applicant was "reasonably required to cure or relieve" him from the effects of his injury as required by section 4600 (Lab. Code, § 5705 ("[t]he burden of proof rests upon the party or lien claimant holding the affirmative of this issue;" Lab.

What proof carried it

The evidence the panel weighed, by kind.

Medical recordsfavours Applicant prevailed

PTP Dr. Shen's reports included detailed job duties, medical and vocational history, and competent physical examination supporting industrial causation.

From the decision · page 6The medical reporting of applicant's PTP thus contains a reasonable medical and vocational history that acknowledges the claimed injury, reviews applicant's job duties and daily exertional levels, accomplishes a competent physical examination, and analyzes the relationship between applicant's work exposures and the established medical diagnoses. Because the medical opinions of the PTP are framed in terms of reasonable medical probability, are based on an accurate history and an examination, and set forth reasoning to support the expert conclusions reached, the reporting of Dr. Shen constitutes substantial medical evidence establishing injury AOE/COE. (Gatten, supra, 145 Cal.App.4th 922, 928; Escobedo, supra, 70 Cal.Comp.Cases 604.)

expert methodologyfavours Applicant prevailed

QME Warren's report lacked analysis, was internally inconsistent, and did not review applicant's job duties or history.

From the decision · page 59.) The QME's analysis of causation is limited to a single sentence that "cooks do not get lung cancer by leaning over a stove." (Ibid.) The QME cites to no medical evidence in support of his conclusions, reviews no medical literature addressing applicant's contentions, and offers no substantive discussion that reflects an understanding of the scope of the injury alleged, or an analysis of the relationship between applicant's work exposures and his alleged injuries. Because the QME's reporting does not reflect a reasonable understanding of the medical issues alleged or an accurate medical and vocational history, and because the report discloses no substantive analysis of the medical issues presented, we conclude that the QME reporting does not rise to the level of substantial evidence.