What the panel ordered
The WCAB panel affirmed the WCJ's Findings and Order denying the medical necessity of the requested Temperpedic adjustable king size bed and denied the Applicant's Petition for Reconsideration.
Petition for Reconsideration filed by Applicant after WCJ decision denying medical treatment for a requested Temperpedic adjustable king size bed; WCAB granted reconsideration to review medical necessity and evidence; WCJ report adopted and incorporated by WCAB panel.
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 found that Dr. Nick's reports did not constitute substantial medical evidence to prove the medical necessity of the requested bed, and the Applicant failed to meet the burden of proof. The WCAB panel adopted and affirmed this finding.
From the decision · page 7The requested medical treatment at issue in this case is Primary Treating Physician Dr. Saeed Nick's request for a Temperpedic adjustable king size bed. The parties stipulated that Defendant did not issue a timely Utilization Review determination for this requested treatment. Thus, the undersigned WCALJ was tasked with determining the medical reasonableness and necessity of the requested bed. The undersigned now reiterates his finding that Dr. Nick's reporting is not substantial medical evidence as it relates to the issue of medical reasonable and necessity of the requested bed. Therefore, Applicant has failed to meet his burden of proof.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Dr. Saeed Nick's reports did not provide substantial medical evidence of the medical necessity of the requested Temperpedic adjustable king size bed.
Favours Defendant prevailed
This failure meant the Applicant did not meet the burden of proof for medical necessity, leading to denial of the requested treatment.
From the decision · page 7The requested medical treatment at issue in this case is Primary Treating Physician Dr. Saeed Nick's request for a Temperpedic adjustable king size bed. The parties stipulated that Defendant did not issue a timely Utilization Review determination for this requested treatment. Thus, the undersigned WCALJ was tasked with determining the medical reasonableness and necessity of the requested bed. The undersigned now reiterates his finding that Dr. Nick's reporting is not substantial medical evidence as it relates to the issue of medical reasonable and necessity of the requested bed. Therefore, Applicant has failed to meet his burden of proof.
Applicant's counsel declared readiness to proceed to hearing despite knowledge of deficient medical evidence and did not seek further development of the record.
Favours Defendant prevailed
This procedural posture indicated the Applicant elected to proceed without additional evidence, supporting denial of further development and affirmance of the WCJ decision.
From the decision · page 9Here, the Petitioner's counsel filed a Declaration of Readiness to Proceed to An Expedited Hearing on March 21, 2022, certifying under the penalty of perjury that she was ready to proceed to hearing and that her discovery was complete on said issue. At the Expedited Hearing, counsel for Defendant suggested allowing additional time to seek clarification from Dr. Nick as to the specific type and brand of bed requested. After attempts to obtain clarification from Dr. Nick's office during the Expedited Hearing failed, Applicant counsel insisted on proceeding forward on the record based on the available documentary evidence. Though the parties procedurally proceeded to an Expedited Hearing instead of a Mandatory Settlement Conference, the parties still participated in the process of framing stipulations and issues, listing exhibits, and disclosing witnesses as contemplated under Labor Code section 5502(d)(3) in order to submit the case for decision.
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.
Requested a Temperpedic adjustable king size bed for treatment of dizziness and disequilibrium; reports did not provide substantial medical evidence of medical necessity as required by regulations and case law.
Reports lacked citation to evidence-based guidelines or significant explanation beyond patient's complaints; did not meet burden of proof for medical necessity.
From the decision · page 7The requested medical treatment at issue in this case is Primary Treating Physician Dr. Saeed Nick's request for a Temperpedic adjustable king size bed. The parties stipulated that Defendant did not issue a timely Utilization Review determination for this requested treatment. Thus, the undersigned WCALJ was tasked with determining the medical reasonableness and necessity of the requested bed. The undersigned now reiterates his finding that Dr. Nick's reporting is not substantial medical evidence as it relates to the issue of medical reasonable and necessity of the requested bed. Therefore, Applicant has failed to meet his burden of proof.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc); State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230
Medical necessity must be proven by substantial medical evidence when Utilization Review is untimely, per Dubon v. World Restoration, Inc. and State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen).
Applicant failed to meet burden of proof for medical necessity of requested treatment due to lack of substantial medical evidence in Dr. Nick's reports.
From the decision · page 7Furthermore, in situations where a Utilization Review determination is untimely, the determination of medical necessity may be made by the WCAB based on substantial medical evidence. (Dubon v. World Restoration, Inc. (79 Cal. Comp. Cases 1298, 1300.) Notwithstanding whatever an employer does (or does not do), an injured employee must still prove that the sought treatment is medically reasonable and necessary. (State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 242.) All parties shall meet the evidentiary burden of proof on all issues by a preponderance of the evidence. (Lab. Code, § 3202.5.)
California Code of Regulations section 9792.21.1
Treating physicians must conduct the medical search sequence for evaluation and treatment of injured workers per California Code of Regulations section 9792.21.1(a).
Dr. Nick did not provide evidence of compliance with the medical search sequence in his reports, undermining the medical necessity claim.
From the decision · page 6California Code of Regulations section 9792.21.1(a) states that treating physicians shall conduct the medical search sequence for the evaluation and treatment of injured workers. A treating physician's requirement to conduct the medical search sequence is not limited to situations where a treating physician is attempting to rebut the MTUS.
What proof carried it
The evidence the panel weighed, by kind.
Dr. Nick's reports lacked citation to evidence-based medical treatment guidelines or scientifically based studies; reports did not provide substantial medical evidence of medical necessity.
From the decision · page 7First, there does not appear to be any dispute that the adjustable bed as requested by Dr. Nick is not addressed by the MTUS. Nonetheless, there is no indication whatsoever confirming whether Dr. Nick complied with Labor Code section 4604.5(d) and the California Code of Regulations section 9792.21.1(a) as he neither referenced the MTUS, or the lack of guidance therefrom, nor cited
Applicant's counsel declared readiness to proceed to hearing despite knowledge of deficient medical evidence; no explanation for failure to obtain further evidence was provided.
From the decision · page 9Here, the Petitioner's counsel filed a Declaration of Readiness to Proceed to An Expedited Hearing on March 21, 2022, certifying under the penalty of perjury that she was ready to proceed to hearing and that her discovery was complete on said issue. At the Expedited Hearing, counsel for Defendant suggested allowing additional time to seek clarification from Dr. Nick as to the specific type and brand of bed requested. After attempts to obtain clarification from Dr. Nick's office during the Expedited Hearing failed, Applicant counsel insisted on proceeding forward on the record based on the available documentary evidence. Though the parties procedurally proceeded to an Expedited Hearing instead of a Mandatory Settlement Conference, the parties still participated in the process of framing stipulations and issues, listing exhibits, and disclosing witnesses as contemplated under Labor Code section 5502(d)(3) in order to submit the case for decision.
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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