ADJ13001939 — California WCAB decision

What the panel ordered

Petition for Reconsideration is denied, affirming the WCJ's Findings and Order that defendant must continue to provide home health care services absent a material change in applicant's condition or circumstance.

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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 prevailedlumbar spine · thoracic spine · neurogenic bowel

The WCJ and Appeals Board found no material change in applicant's medical condition or circumstance to justify discontinuing home health care. Defendant failed to meet its burden to show the treatment was no longer medically necessary. The Appeals Board retained jurisdiction because no timely UR decision was valid to trigger IMR.

The facts that decided it

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

Applicant sustained industrial injury to lumbar spine, thoracic spine, and neurogenic bowel on September 9, 2019, and has required home health care services authorized since July 8, 2022.

Favours Applicant prevailed

Established the basis for ongoing medical treatment entitlement under Labor Code section 4600(a).

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 (Lab. Code, 4600(a)).

The Appeals Board applied this standard to determine that home health care services authorized as medically necessary must continue absent a material change in condition.

From the decision · page 5Section 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. The Oaks Farm (2014) 79 Cal.Comp.Cases 910

An employer may not unilaterally cease authorized medical treatment without substantial medical evidence of a change in the employee's condition (Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910).

The Appeals Board relied on Patterson to hold that defendant must continue home health care absent a material change in applicant's condition.

From the decision · page 5In 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:

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298

Disputes regarding a timely UR decision on medical necessity must be resolved by Independent Medical Review (Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298).

The Appeals Board held it retains jurisdiction only if no timely UR decision is valid to trigger IMR.

From the decision · page 9Defendant further contends we lack the jurisdiction to resolve the instant medical treatment dispute because the UR decision was valid and timely. (Petition, at p. 4:2.) In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) (Dubon II), the Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If the UR decision is timely, the Appeals Board has no jurisdiction to address disputes regarding the UR because "[a]ll other disputes regarding a UR decision must be resolved by IMR." (Id. at p. 1299.) As noted in the Dubon II decision, section 4604 provides that "[c]ontroversies between employer and employee arising under this chapter shall be determined by the appeals board, upon the request of either party, except as otherwise provided by Section 4610.5." (Id. at p. 1305.) Sections 4610 and 4610.5 expressly define a UR decision addressing treatment "based in whole or in part on medical necessity." In Dubon II, the Appeals Board found that sections 4610.5 and 4610.6 "specifically provide that where there is a dispute regarding a UR decision on `medical necessity,' the dispute shall be resolved only by IMR." (Id. at p. 1309.) However, "where there is no timely UR decision subject to IMR, the issue of medical necessity must be determined by the WCAB." (Id. at p. 1312.)

ADJ13001939 · January 13, 2025

What the panel ordered

What was disputed, and how it came out

The facts that decided it

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What the panel did with the medical opinions

The rules the panel named

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