ADJ12812938 — California WCAB decision

What the panel ordered

Petition for Reconsideration denied, affirming WCJ's findings of industrial injury and reasonableness of medical treatment by Dr. Schames.

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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 prevailedteeth · jaw · temporomandibular joint

The WCJ relied on the treating physician Dr. Schames's detailed medical opinion based on objective clinical findings and reasonable medical probability, which was substantial evidence supporting industrial causation; the WCAB adopted and incorporated the WCJ's report and denied reconsideration.

From the decision · page 4Here, the undersigned WCJ relied on the treating physician's report of Dr. Schames, dated May 14, 2021, on page 9, who wrote the following regarding causation:

Medical treatment / UR / IMRApplicant prevailedteeth · jaw · temporomandibular joint

The WCJ found the medical treatment reasonable and consistent with Labor Code 4604.5 based on Dr. Schames's detailed medical necessity opinion; the WCAB adopted and incorporated the WCJ's report and denied reconsideration.

The rules the panel named

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

Applicant must show industrial causation by a preponderance of the evidence, with substantial medical evidence based on reasonable medical probability.

The WCJ relied on Dr. Schames's medical opinion as substantial evidence of industrial causation, which the WCAB adopted and incorporated in denying reconsideration.

From the decision · page 4For an applicant to meet his or her burden of proof by a preponderance of the evidence, pursuant to Labor Code § 3202.5, he or she must establish that an injury was caused by his or her employment and occurred while he or she was working. [Labor Code § 3600(a).]

Labor Code 4604.5; Torres v. AJC Sandblasting (2012) 77 Cal. Comp. Cases 1113; Frontline Medical Associates, Inc. v. Workers' Comp. Appeals Bd. (Lopez) (2015) 80 Cal. Comp. Cases 380; Sierra Pacific Industries v. Workers' Comp. Appeals Bd. (Chatham) (2006) 71 Cal. Comp. Cases 714

Medical treatment must be reasonable and consistent with Labor Code 4604.5 and ACOEM/MTUS guidelines; lien claimant bears burden of proof for reasonableness.

The WCJ found Dr. Schames's treatment reasonable and consistent with the law and guidelines, which the WCAB adopted and incorporated in denying reconsideration.

From the decision · page 6Labor Code § 4604.5 provides that the American College of Occupational and Environmental Medicine's Occupational Medicine Practice (ACOEM) Guidelines or any Medical Treatment Utilization Schedule (MTUS) adopted by the Administrative Director are presumed to be correct on the issue of reasonable of the medical treatment. The same section also states that this presumption is rebuttable by scientific medical evidence establishing that a variance from the ACOEM Guidelines or MTUS is reasonably required. Therefore, in order to meet this burden of proof, a lien claimant is required to show that the disputed medical treatment was reasonably necessary to cure or relieve from the effects of the injury and that this treatment was consistent with ACOEM Guidelines or the MTUS. [Frontline Medical Associates, Inc. v. Workers' Comp. Appeals Bd. (Lopez) (2015) 80 Cal. Comp. Cases 380 (writ denied)] This requirement applies retroactively to all open cases, regardless of the date of injury or the date of medical treatment. [Sierra Pacific Industries v. Workers' Comp. Appeals Bd. (Chatham) (2006) 71 Cal. Comp. Cases 714.] In this case, notwithstanding the articulated criticisms of the Defendant, based on the medical report of Dr. Schames dated May 14, 2021, on pages 12 to 13, he wrote as follows regarding medical necessity:

ADJ12812938 · May 28, 2024

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