What the panel ordered
Defendant's Petition for Reconsideration of the September 12, 2023 Opinion and Order Granting Petition for Reconsideration and Decision After Reconsideration is denied.
Defendant seeks reconsideration of the September 12, 2023 Opinion and Order Granting Petition for Reconsideration and Decision After Reconsideration, which granted applicant's July 14, 2023 Petition for Reconsideration, rescinded the June 16, 2023 Findings and Award and Orders, and substituted a new Findings and Award finding injury to low back and left elbow but not hip, and entitlement to an additional panel in internal medicine.
This docket was decided more than once. Shown here is the latest released decision; we also hold September 12, 2023.
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.
Applicant exercised due diligence in requesting the additional PQME and there was a dispute necessitating the additional panel; defendant's denial of the referral and refusal to agree to the panel justified the order for the additional PQME.
From the decision · page 5Turning to the merits of defendant's petition, defendant contends that applicant did not make a diligent good faith effort to obtain a PQME in internal medicine and that there was no evidence of a dispute to warrant a PQME in internal medicine.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Applicant repeatedly requested an additional PQME in internal medicine throughout the case, including before and at trial.
Favours Applicant prevailed
Demonstrates due diligence in obtaining the additional PQME, supporting applicant's entitlement.
From the decision · page 5First, applicant exercised due diligence in repeatedly requesting the additional PQME and was therefore not in violation of Labor Code section 5502. (Lab. Code, § 5502(d)(3).) Applicant requested the additional PQME multiple times throughout this case, including before and at trial. (12/21/22 PTCS, p. 3; 12/21/22 MOH/SOE, p. 2.)
Defendant denied the Request for Authorization for internal medicine evaluation and refused to agree to the additional PQME panel.
Favours Applicant prevailed
Created a dispute necessitating the additional PQME and justified the WCJ's order for the panel.
From the decision · page 5claimed conditions (12/21/22 MOH/SOE, p. 2) and denied the RFA for referral to a consulting physician. (Ex. A, p. 1.) Applicant could not obtain additional evaluations pursuant to AD Rule 31.7(b)(1) as defendant would not agree to the additional PQME and therefore had to rely on the
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.
Discussed lumbar spine, left elbow, left hip; recommended internal medicine evaluation and treatment due to persistent complaints.
Applicant's persistent complaints warranted referral to internal medicine specialist.
From the decision · page 2In the Primary Treating Physician's (PTP) Progress Report (PR-2 Report) of January 25, 2021, PTP Dr. Shahab Mahboubian, D.O., in orthopedic surgery, discussed applicant's lumbar spine, left elbow, and left hip and also made a specialty referral for an internal medicine evaluation and treatment. (Ex. 2, PR-2 Report, pp. 1-3.) Dr. Mahboubian stated "The patient will [be] referred for evaluation and/or diagnostic testing in the capacity of internal medicine evaluation and/or testing per MTUS GUIDES 8 C.C.R. § 9792.20-9792.26 Page 1 of 127, `If the complaint persists, the physician needs to reconsider the diagnosis and decide whether a specialist evaluation is necessary.'" (Ex. 2, p. 3.)
Conducted orthopedic evaluation; did not address elbow laceration, blood infection, or psychological complaints; found applicant permanent and stationary.
From the decision · page 2Agreed Medical Evaluator (AME) in orthopedic surgery Dr. Peter M. Newton, M.D., conducted an orthopedic evaluation of applicant on February 24, 2021. (Ex. X1, AME Report of Dr. Newton dated 2/24/21.) Applicant disclosed her injury and treatment to him, including the infection in her elbow. (Ex. X1, p. 3.) Dr. Newton also noted that applicant had high blood pressure, which was controlled with medication, and that she suffered from depression, anxiety, stress, headaches, and sleep disturbances due to her injuries. (Ex. X1, pp. 7-8.) After Dr. Newton re-examined applicant on May 18, 2021, he found her permanent and stationary. (Ex. X2, AME Report of Dr. Newton dated 5/19/21, p. 12.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code, 5502(d)(3)
Labor Code section 5502(d)(3) regarding due diligence in obtaining a PQME
Applicant exercised due diligence in repeatedly requesting the additional PQME panel.
From the decision · page 5First, applicant exercised due diligence in repeatedly requesting the additional PQME and was therefore not in violation of Labor Code section 5502. (Lab. Code, § 5502(d)(3).) Applicant requested the additional PQME multiple times throughout this case, including before and at trial. (12/21/22 PTCS, p. 3; 12/21/22 MOH/SOE, p. 2.)
Cal. Code Regs., tit. 8, 31.7
Administrative Director Rule 31.7 regarding additional PQME panels in different specialties
There was a dispute necessitating an additional PQME in internal medicine; defendant denied the referral and refused to agree to the panel, justifying the order for the additional PQME.
From the decision · page 5Further, there was a dispute that necessitated an additional PQME in internal medicine. If an additional QME panel in a different specialty is necessary, Administrative Director (AD) Rule 31.7 provides, in relevant part:
What proof carried it
The evidence the panel weighed, by kind.
Applicant's repeated requests for additional PQME in internal medicine and defendant's denial of referral and refusal to agree to panel
From the decision · page 5claimed conditions (12/21/22 MOH/SOE, p. 2) and denied the RFA for referral to a consulting physician. (Ex. A, p. 1.) Applicant could not obtain additional evaluations pursuant to AD Rule 31.7(b)(1) as defendant would not agree to the additional PQME and therefore had to rely on the
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
- Issues, outcomes and weights were extracted by AI and released only where the source passage checked. Read the official decision before relying on anything here. Not legal advice.
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