ADJ1408322 · August 4, 2025

The WCJ found substantial evidence that the treatment provided by the lien claimant was reasonable and necessary to cure or relieve the effects of the industrial lumbar spine injury, supported by objective diagnostic studies and IMR determination.

From the decision · page 1Defendant seeks reconsideration of the Findings and Order (F&O) issued on April 30, 2025 by the workers' compensation administrative law judge (WCJ). Therein, the WCJ found in part that the parts of body injured include the lumbar spine only, however, this does not limit the scope of treatment under Labor Code section 4600; applicant was entitled to coverage for treatment expense; the treatment provided by Sleep Treatment Clinic (lien claimant) was reasonably required; the record needs to be developed on the issue of whether the charges were reasonable; the Labor Code section 4903.05 Declaration was not false; lien claimant did serve a request for authorization (RFA); the defendant did not issue a timely utilization review response to the RFA; the defendant did not timely and properly defer utilization review; and the issue of disregarding the RFA of a secondary treater is not relevant.

Applicant diagnosed with sleep breathing respiratory disorder related to industrial lumbar spine injury supported by objective diagnostic studies and PTP's diagnosis.

Favours Applicant prevailed

Supported finding that treatment by lien claimant was reasonable and necessary.

From the decision · page 5Medical, surgical, chiropractic, acupuncture, licensed clinical social worker, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury shall be provided by the employer. (§ 4600(a).) Next, defendant contends that there is no substantial evidence that treatment provided by lien claimant was reasonable or necessary to cure or relieve from the effects of the industrial lumbar spine injury. At time of treatment provided by lien claimant, Richard Hubbard, M.D., served as the applicant's PTP. Initially, on August 11, 2011, applicant reported symptoms including insomnia that she believed developed due to her industrial lumbar spine injury to her medical treatment provider. (Exhibit 9 at p. 3.) As an activity of daily living, applicant's sleep function was reported as follows: "The patient is unable to maintain a restful sleep.

Defendant failed to respond to multiple RFAs and denied emergency treatment without proper utilization review, failing to meet duty to provide medical treatment.

Favours Applicant prevailed

Supported finding that defendant waived objections and became liable for self-procured treatment.

From the decision · page 9Here, the WCJ clearly described defendant's responses or lack thereof to applicant's repeated requests for medical treatment:

Issued Sleep Disordered Breathing Respiratory Diagnostic Study and Report confirming moderate pathological sleep breathing respiratory disorder.

From the decision · page 5The patient has frequent sleep wake schedules, affecting daytime attention and concentration; alertness, energy level; causing irritability and nocturnal sleep pattern." (Id. at p. 5.) Thereafter, Dr. Hubbard referred applicant for a two-night Sleep Disordered Breathing Respiratory Diagnostic Study (SDBR Study). (Exhibit 10 at p. 1.) On July 29, 2015, Gurdip Flora, M.D., issued a Sleep Disordered Breathing Respiratory Diagnostic Study and Report that stated: "The two-night SDBR Study reveals that the patient suffers from a moderate pathological sleep breathing respiratory disorder." (Exhibit 10 at p. 4.) Hence, per an objective, diagnostic study applicant had a sleep breathing respiratory disorder. On August 18, 2015, Mayer Schames, D.D.S. issued an RFA for Immediate Emergency Medical Treatment of an Obstructive Airway Oral Appliance to treat applicant's diagnosis of Obstructions of the Airway During Sleep. (Exhibit 3 at p. 1.)

Diagnosed insomnia related to industrial lumbar spine injury and issued multiple Requests for Authorization for treatment and testing related to sleep disorders.

From the decision · page 5Medical, surgical, chiropractic, acupuncture, licensed clinical social worker, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury shall be provided by the employer. (§ 4600(a).) Next, defendant contends that there is no substantial evidence that treatment provided by lien claimant was reasonable or necessary to cure or relieve from the effects of the industrial lumbar spine injury. At time of treatment provided by lien claimant, Richard Hubbard, M.D., served as the applicant's PTP. Initially, on August 11, 2011, applicant reported symptoms including insomnia that she believed developed due to her industrial lumbar spine injury to her medical treatment provider. (Exhibit 9 at p. 3.) As an activity of daily living, applicant's sleep function was reported as follows: "The patient is unable to maintain a restful sleep.

Provided emergency medical treatment with an Obstructive Airway Oral Appliance for nocturnal obstructions of the airway, supported by objective diagnostic studies and IMR determination of medical necessity.

From the decision · page 6On September 1, 2015, David Schames, D.D.S., issued an Examination Report for Treatment of the Objectively Documented Nocturnal Obstructions of the Airway. (Exhibit 2.) Dr. Schames reviewed the SDBR Study and reported:

Labor Code section 4600

Labor Code section 4600 requires employer to provide reasonable and necessary medical treatment to cure or relieve effects of industrial injury.

Applied to determine defendant's liability for medical treatment.

From the decision · page 5Contrary to defendant's contention, the WCJ did not find that applicant suffered industrial injury in the form of nature and extent to sleep, oral or cranial. (05/20/2025 Petition for Reconsideration at p. 2:17-18.) Rather, the WCJ found that applicant was entitled to the medical treatment provided by lien claimant under section 4600, which states that:

Labor Code section 4903.05(c)

Labor Code section 4903.05(c) declaration requirements for lien claimant.

Lien claimant filed appropriate declarations including section 4903.05(c) declaration.

From the decision · page 4On 12 August 2016, SLEEP TREATMENT CLINICS filed its lien in this case which included the appropriate declarations required at the time including the Labor Code § 4903.8 declaration and the Rule 10770.5(a) declaration. Also in 2016, the Legislature passed Labor Code § 4903.05(c) which was signed into law providing for another declaration. The lien claimant responded by filing a document entitled Supplemental Lien Form and § 4903.05(c) Declaration dated 20 April 2017. In it, Dr. Schames states that he, "HAS DOCUMENTATION THAT MEDICAL TREATMENT HAS BEEN NEGLECTED OR UNREASONABLY REFUSED TO THE EMPLOYEE AS PROVIDED IN LABOR CODE § 4600."

Braewood Convalescent Hosp. v. Workers' Comp. Appeals Bd. (1983) 34 Cal. 3d 159

Employer's duty to actively provide medical treatment and consequences of refusal under Braewood Convalescent Hosp. v. WCAB (1983) 34 Cal.3d 159.

Applied to find defendant failed to meet duty to provide medical treatment and became liable for self-procured treatment.

From the decision · page 8Court has discussed the consequences of an employer's refusal to provide medical treatment: [T]he employer is given initial authority to control the course of the injured employee's medical care. Section 4600 requires more than a passive willingness on the part of the employer to respond to a demand or request for medical aid. This section requires some degree of active effort to bring to the injured employee the necessary relief. Upon notice of the injury, the employer must specifically instruct the employee what to do and whom to see, and if the employer fails or refuses to do so, then he loses the right to control the employee's medical care and becomes liable for the reasonable value of self- procured medical treatment.

Ramirez

Employer's duty to investigate and act with expedition under Ramirez.

Applied to find defendant failed to investigate and act timely to provide benefits.

From the decision · page 8Cal.Comp.Cases 383] (Ramirez), the court of appeal observed that:

Applicant's symptoms and objective diagnostic studies confirmed sleep breathing respiratory disorder related to industrial lumbar spine injury.

From the decision · page 5Medical, surgical, chiropractic, acupuncture, licensed clinical social worker, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury shall be provided by the employer. (§ 4600(a).) Next, defendant contends that there is no substantial evidence that treatment provided by lien claimant was reasonable or necessary to cure or relieve from the effects of the industrial lumbar spine injury. At time of treatment provided by lien claimant, Richard Hubbard, M.D., served as the applicant's PTP. Initially, on August 11, 2011, applicant reported symptoms including insomnia that she believed developed due to her industrial lumbar spine injury to her medical treatment provider. (Exhibit 9 at p. 3.) As an activity of daily living, applicant's sleep function was reported as follows: "The patient is unable to maintain a restful sleep.

Defendant's failure to respond to multiple Requests for Authorization and denial letters without proper utilization review process.

From the decision · page 9Here, the WCJ clearly described defendant's responses or lack thereof to applicant's repeated requests for medical treatment: