ADJ14145123 — California WCAB decision

What the panel ordered

Petition for Reconsideration granted; final decision deferred pending further review of the merits and the record.

Applicant sought reconsideration of the WCJ's Findings and Award dated September 22, 2025, regarding entitlement to ongoing home health care services. The Appeals Board granted reconsideration and deferred a final decision pending further review of the merits and the record.

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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 / IMRRemandedrespiratory system

The Appeals Board found the record may not contain substantial evidence to support the WCJ's decision regarding ongoing home health care, and further development of the record is necessary before a final decision can be made.

From the decision · page 7employer's liability under the interplay of Braewood Convalescent Hosp. and section 4610. Thus, based on our preliminary review, we are not persuaded that there is substantial evidence in the record to support the WCJ's decision. Taking into account the statutory time constraints for acting on the petition, and based upon our initial review of the record, we believe reconsideration must be granted to allow sufficient opportunity to further study the factual and legal issues in this case. We believe that this action is necessary to give us a complete understanding of the record and to enable us to issue a just and reasoned decision. Reconsideration is therefore granted for this purpose and for such further proceedings as we may hereafter determine to be appropriate.

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.

AMERelied upon

Recommended home healthcare for applicant for four hours per day due to residual cognitive, behavioral, and emotional sequelae associated with long COVID.

Report cited as basis for home healthcare recommendation and ongoing need for care.

From the decision · page 8Agreed Medical Evaluator (AME) Robert Tomaszewski, M.D.,'s report dated March 15, 2023, indicates that applicant contracted COVID on December 11, 2020, and has residual cognitive, behavioral, and emotional sequela associated with long COVID. Dr. Tomaszewski's report includes diagnostics by QME Internal Medicine Eli Hendel, M.D., who found applicant to have post COVID-19 syndrome with cognitive dysfunction. Dr. Hendel concluded that the most common symptoms of COVID are severe fatigue and the crippling exhaustion which impairs the ability to perform activities of daily living. He summarized additional neurological symptoms resulting from the COVID infection and states that he considers applicant incompetent to care for himself. (Ex. 2, pp. 15-16.)

QMERelied upon · Internal Medicine

Diagnosed applicant with post COVID-19 syndrome with cognitive dysfunction and concluded applicant incompetent to care for himself.

Diagnostics included in AME report and referenced as supporting ongoing need for home health care.

From the decision · page 8Agreed Medical Evaluator (AME) Robert Tomaszewski, M.D.,'s report dated March 15, 2023, indicates that applicant contracted COVID on December 11, 2020, and has residual cognitive, behavioral, and emotional sequela associated with long COVID. Dr. Tomaszewski's report includes diagnostics by QME Internal Medicine Eli Hendel, M.D., who found applicant to have post COVID-19 syndrome with cognitive dysfunction. Dr. Hendel concluded that the most common symptoms of COVID are severe fatigue and the crippling exhaustion which impairs the ability to perform activities of daily living. He summarized additional neurological symptoms resulting from the COVID infection and states that he considers applicant incompetent to care for himself. (Ex. 2, pp. 15-16.)

The rules the panel named

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

Lab. Code § 4600

Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of the industrial injury. If the employer neglects to do so, the employer is liable for reasonable expenses incurred by or on behalf of the employee in providing treatment.

Applied to determine employer's liability for home health care services.

From the decision · page 54.) However, the existing record appears to only contain one original request for authorization (RFA) dated August 22, 2024. (Exhibit 10, PDF page 1.) We highlight several legal principles that may be relevant to our consideration of this matter. Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of the industrial injury. (Lab. Code, § 4600(a).) If the employer neglects to do so, "the employer is liable for reasonable expenses incurred by or on behalf of the employer in providing treatment." (Lab. Code § 4600(a).) The Supreme Court 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

Lab. Code § 4610

An employer's review of an employee's medical treatment requests are governed solely by utilization review (UR).

Cited regarding the process for reviewing treatment requests.

From the decision · page 6in section 4610. An employer's review of an employees' medical treatment requests are governed solely by UR. (Lab. Code, § 4610(g); State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236 [73 Cal.Comp.Cases 981].)

Cal. Code Regs., tit. 8, § 10109; Braewood Convalescent Hosp. v. WCAB

The employer has an affirmative duty to investigate the need for medical treatment; UR does not abrogate this duty.

Cited to emphasize the ongoing duty to investigate and provide benefits.

From the decision · page 6A defendant, however, has an affirmative duty to investigate the need for medical treatment. The UR processes do not abrogate the claims administrator's duty to investigate whether benefits are due. (Cal. Code Regs., tit. 8, § 10109; see also Braewood Convalescent Hospital, supra, at p. 165).

What proof carried it

The evidence the panel weighed, by kind.

Testimony and credibilityfavours Applicant prevailed

Testimony of applicant's wife (guardian ad litem) regarding applicant's compromised mental state, safety issues, and need for supervision and home care.

From the decision · page 5III. Applicant asserts defendant has an obligation to provide ongoing HHC beyond the October 4, 2024 Notice of Utilization Review (UR), which approved 4 hours per day, 5 days of week of HHC, for a period of 60 days. (Ex. 4.) At trial applicant's wife, who is also his guardian ad litem, testified to his compromised mental state and resulting safety issues. She supervises him for safety, cooks, washes his clothes, and cleans the house. She is micromanaging him, because it is like having a toddler and she must be there and step in in case something happens. She does have experience in home healthcare but there is a difference going somewhere to do home healthcare then leaving as a job, because it is a completely different thing "when you're taking care of a spouse as it doesn't stop, and you don't get a break". (MOH/SOE, 8/14/25, p. 4:18-20, p. 5:22-24, p. 6: 12-15,19-21.) While noting that applicant has completed 270 hours in an intense outpatient Brain Injury Program at Institutes of Health, with subjective and objective improvements in balance, cognition, headaches, and dizziness, he was still pending installation of a previously authorized durable medical equipment (DME) and provision of a home health care aide as recommended by his treating physicians. (Ex. 6, April 7,4; Ex. 5, 6/5/25, at p.

Medical recordsfavours neutral

Institutes of Health treatment report documenting applicant's progress and discharge to independent home program, but absence of recent AME/QME reports digesting these records.

From the decision · page 8The Institutes of Health treatment report dated December 24, 2024, is a comprehensive summary of applicant's neurologic status after he completed 270 hours of participation in the Brain Rehabilitation Program (BIP) with subjective and objective progress documented. Applicant was discharged and transitioned to a fully independent home and fitness club-based exercise program. (Ex. 8, p.17.)

ADJ14145123 · December 29, 2025

What the panel ordered

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