ADJ9218482 · August 7, 2023

The petition for reconsideration was denied because the WCJ's findings that treatment by Dr. Haronian was reasonably required and that certain charges denied by Utilization Review and not appealed through Independent Medical Review are disallowed were adopted and incorporated.

From the decision · page 1We have considered the allegations of the Petition for Reconsideration, the contents of the Report and the Opinion on Decision of the workers' compensation administrative law judge (WCJ) with respect thereto. Based on our review of the record, and for the reasons stated in the WCJ's Report and Opinion on Decision, which are both adopted and incorporated herein, we will deny reconsideration.

Treatment by Dr. Haronian for spine, left shoulder, left wrist, and left knee was reasonably required to cure or relieve from the effects of the industrial injury.

Favours Defendant prevailed

Supports denial of petition for reconsideration and reimbursement of lien charges.

From the decision · page 5In light of the findings above, it is found that the treatment furnished by primary treating physician Edwin Haronian, M.D. for spine, left shoulder, left wrist, and left knee was reasonably required to cure or relieve from the effects of the industrial injury.

No appeal through Independent Medical Review for Utilization Review denials of treatment charges.

Favours Defendant prevailed

Supports disallowance of charges for treatment denied by Utilization Review and not appealed.

From the decision · page 6No UR denials were offered in evidence, however denials are documented in various Dr. Haronian reports (Lien Claimant's Exhibits 42, 27, 53 and 9 again listed chronologically). There is no evidence of appeal through the IMR process.

Treatment for spine, left shoulder, left wrist, and left knee was reasonably required to cure or relieve from the effects of the industrial injury.

The WCJ found the treatment by Dr. Haronian reasonably required for the industrial injury.

From the decision · page 5In light of the findings above, it is found that the treatment furnished by primary treating physician Edwin Haronian, M.D. for spine, left shoulder, left wrist, and left knee was reasonably required to cure or relieve from the effects of the industrial injury.

Applicant did not suffer industrially caused injury to right knee, right shoulder, legs (other than left knee), or neck as claimed.

The WCJ relied on Dr. Creamer's opinion to exclude injury to certain body parts from industrial injury.

From the decision · page 5Based on the opinion of Ray L. Creamer, M.D., agreed medical examiner, (report of 04/25/2018, Lien Claimant's Exhibit 4) it is found that applicant did not suffer industrially caused injury to his right knee or right shoulder or legs (other than his left knee) or neck as claimed.

Cal. Code of Reg. Sec. 9792.5.5

Cal. Code of Reg. Sec. 9792.5.5 governs the second bill review process for medical treatment charges.

The petitioner's contention that failure to request second bill review should result in the bill being deemed satisfied was rejected.

From the decision · page 3II. CONTENTIONS Petitioner contends that lien claimant's failure to request second bill review pursuant to Cal. Code of Reg. Sec. 9792.5.5 of petitioner's explanations of review (EOBs) required a finding that the bill was to be "deemed satisfied" and that defendant is not "liable for any further payment."

Official Medical Fee Schedule

Official Medical Fee Schedule governs reimbursement of allowed medical treatment services.

The charges for allowed medical treatment services are to be reimbursed based on the Schedule.

From the decision · page 5The value of the allowed medical treatment services provided by lien claimant is governed by the Official Medical Fee Schedule and are to be reimbursed based on the Schedule. Jurisdiction is reserved over any dispute as to how to apply the OMFS.

Petitioner does not contest the finding of industrial injury to lumbar spine, left shoulder, left wrist, left knee, and psyche.

From the decision · page 3III. FACTS Petitioner does not contest the finding that applicant suffered the industrial injury alleged. Petitioner does not contest the finding that treatment furnished by primary treating physician Edwin Haronian, M.D. for spine, left shoulder, left wrist, left knee was reasonably required to cure or relieve from the effects of that industrial injury, or the finding that the charges for treatment for treatment denied by Utilization Review and not appealed through the Independent Medical Review process are disallowed. The decision under reconsideration, in a nutshell, is that EOBs based on a lack of necessity of treatment and allowed no "amount" do not entirely defeat any claim for those services.

No evidence of appeal through the Independent Medical Review process for Utilization Review denials.

From the decision · page 6No UR denials were offered in evidence, however denials are documented in various Dr. Haronian reports (Lien Claimant's Exhibits 42, 27, 53 and 9 again listed chronologically). There is no evidence of appeal through the IMR process.