ADJ11726227 — California WCAB decision

ADJ11726227 · September 22, 2023

The WCAB granted the Petition for Reconsideration, rescinded the Findings of Fact and Order issued on June 27, 2023, and substituted findings that defendant failed to meet its burden to show a change of circumstances or condition to discontinue home health care services. All other issues were deferred.

Issues decided

Medical opinions weighed

Authorities named

District office

Van Nuys

What the panel ordered

Defendant sought reconsideration of the Findings of Fact and Order issued on June 27, 2023, which the WCJ had issued. The WCAB granted reconsideration and rescinded the prior F&O, substituting new findings.

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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 prevailedhead · brain

Defendant failed to meet its burden to show a change in applicant's condition or circumstances to justify discontinuing previously authorized home health care services, supported by substantial medical evidence from Drs. Huang and Franc.

From the decision · page 25For the foregoing reasons, IT IS ORDERED that the Petition for Reconsideration of the Findings of Fact and Order issued on June 27, 2023 is GRANTED. IT IS FURTHER ORDERED, as the Decision After Reconsideration, that the Findings of Fact and Order issued on June 27, 2023 is RESCINDED and the following is SUBSTITUTED therefor:

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. Huang testified there was no change in applicant's condition that would warrant termination of home health care services. He issued RFAs supporting continued care.

Dr. Huang is the primary treating physician and in the best position to opine on medical necessity; his testimony and reports were credited as substantial evidence.

From the decision · page 1Defendant seeks reconsideration of the Findings of Fact and Order (F&O) issued on June 27, 2023, wherein the workers' compensation administrative law judge (WCJ) found, in pertinent part, that (1) while employed by defendant as a Ready-Mix concrete driver on May 25, 2018, applicant sustained injury arising out of and in the course of employment to the head and brain, and that the issues as to claimed body parts are deferred; (2) applicant's condition is found to be `catastrophic'; (3) Labor Code Section 4610(i)(3)1 is applicable to this case because applicant faced an imminent and serious threat due to his medical condition; (4) none of defendant's Utilization Reviews (UR) were conducted within seventy-two hours; (5) Independent Medical Review (IMR) does not apply to an untimely UR or a Patterson fact pattern; (6) pursuant to Patterson, if an employer authorizes medical services, the applicant does not have the burden of proving the ongoing reasonableness and necessity of the services; (7) defendant failed to meet the burden of showing that the continued provision of services is no longer reasonably required due to a change of applicant's circumstances or condition; (8) the medical reports of Drs. Huang and Franc, and Dr. Huang's testimony, constitute substantial medical evidence; and (9) all other issues are moot.

QMERelied upon

Dr. Franc supported the medical necessity of continued home health care services.

Dr. Franc's medical reports were considered substantial medical evidence supporting continued care.

From the decision · page 1Defendant seeks reconsideration of the Findings of Fact and Order (F&O) issued on June 27, 2023, wherein the workers' compensation administrative law judge (WCJ) found, in pertinent part, that (1) while employed by defendant as a Ready-Mix concrete driver on May 25, 2018, applicant sustained injury arising out of and in the course of employment to the head and brain, and that the issues as to claimed body parts are deferred; (2) applicant's condition is found to be `catastrophic'; (3) Labor Code Section 4610(i)(3)1 is applicable to this case because applicant faced an imminent and serious threat due to his medical condition; (4) none of defendant's Utilization Reviews (UR) were conducted within seventy-two hours; (5) Independent Medical Review (IMR) does not apply to an untimely UR or a Patterson fact pattern; (6) pursuant to Patterson, if an employer authorizes medical services, the applicant does not have the burden of proving the ongoing reasonableness and necessity of the services; (7) defendant failed to meet the burden of showing that the continued provision of services is no longer reasonably required due to a change of applicant's circumstances or condition; (8) the medical reports of Drs. Huang and Franc, and Dr. Huang's testimony, constitute substantial medical evidence; and (9) all other issues are moot.

ADJ11726227 · September 22, 2023

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The facts that decided it

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