ADJ12056705 — California WCAB decision

ADJ12056705 · December 27, 2024

The Petition for Reconsideration filed by Defendant was denied, affirming the WCJ's Findings of Fact and Order that the defendant must continue to authorize medical treatment at the Centre for Neuro Skills unless a material change in applicant's condition or circumstance is established.

Issues decided

Medical opinions weighed

Authorities named

District office

Van Nuys

What the panel ordered

Defendant filed a Petition for Reconsideration of the September 24, 2024 Findings of Fact and Order by the WCJ, which was denied by the WCAB panel on December 27, 2024.

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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.

Jurisdiction / venueApplicant prevailedhead · brain · eyes · ears · back · face · neck · right foot · urological system · sexual function · teeth · TMJ · sleep

The WCJ and WCAB found that defendant did not establish a material change in applicant's condition to justify cessation of treatment, thus WCAB retains jurisdiction and defendant must continue authorizing treatment at CNS.

From the decision · page 1Defendant Travelers Property Casualty Company of America (defendant) seeks reconsideration of the September 24, 2024 Findings of Fact and Order (F&O), wherein the workers' compensation administrative law judge (WCJ) found that applicant, while employed as a driver on October 19, 2018, sustained industrial injury to his head, brain, eyes, ears, back, face, neck, right foot, urological dysfunction, sexual dysfunction, teeth, TMJ, and sleep. The WCJ found that the Workers' Compensation Appeals Board (WCAB) has jurisdiction to resolve the instant medical dispute and ordered defendant to continue to authorize medical treatment at the Centre for Neuro Skills (CNS) unless and until defendant can establish a material change in applicant's condition or circumstance.

The facts that decided it

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

Applicant sustained industrial injury in a rollover motor vehicle accident on October 19, 2018, resulting in multiple injuries including traumatic brain injury.

Favours Applicant prevailed

Established the basis for ongoing medical treatment needs.

Defendant's Utilization Review non-certification was based on lack of material change in applicant's condition, supporting ongoing treatment necessity.

Favours Applicant prevailed

Supported applicant's position that no material change occurred to justify stopping treatment.

From the decision · page 8Here, we agree with the WCJ that defendant has not carried that burden. Defendant offers no medical reporting to establish a material change in applicant's condition that would otherwise necessitate a reevaluation of a medically necessary treatment modality. (Report, at p. 2.) We also observe that insofar as defendant's April 10, 2024 UR decision cites to a lack of significant interval change in applicant's condition in the two months prior to the request as a basis for non- certification, this actually supports applicant's position that there has been no material change in his condition. (Ex. 13, Utilization Review Determination, dated April 10, 2024, at p. 3; Answer, at p.

No medical evidence was presented by defendant to establish a material change in applicant's condition or circumstances.

Favours Applicant prevailed

Defendant failed to meet burden to justify cessation of treatment.

From the decision · page 8Here, we agree with the WCJ that defendant has not carried that burden. Defendant offers no medical reporting to establish a material change in applicant's condition that would otherwise necessitate a reevaluation of a medically necessary treatment modality. (Report, at p. 2.) We also observe that insofar as defendant's April 10, 2024 UR decision cites to a lack of significant interval change in applicant's condition in the two months prior to the request as a basis for non- certification, this actually supports applicant's position that there has been no material change in his condition. (Ex. 13, Utilization Review Determination, dated April 10, 2024, at p. 3; Answer, at p.

The rules the panel named

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

Labor Code section 4600(a)

Labor Code section 4600(a) - entitlement to medical treatment reasonably required to cure or relieve effects of industrial injury.

Defendant must continue to provide treatment unless a material change in condition is shown.

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.)

Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910

Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910 - employer burden to show change in condition to cease treatment.

Employer cannot unilaterally cease treatment without substantial evidence of change in 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

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 - WCAB jurisdiction over timely UR decisions and medical necessity disputes.

WCAB retains jurisdiction when no timely UR decision exists; otherwise IMR resolves UR disputes.

From the decision · page 8Defendant 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, emphasis in original.) 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

ADJ12056705 · December 27, 2024

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