ADJ12973118 — California WCAB decision

What the panel ordered

May 19, 2022 Findings and Order affirmed except amended to award future medical care; no temporary or permanent disability awarded

Petition for reconsideration granted to study factual and legal issues; decision after reconsideration issued

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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 / IMRApplicant prevailed

Substantial medical evidence showed applicant may require future medical care, including PTP and QME reports recommending possible future treatment and an air purifier.

From the decision · page 2In this case, applicant's primary treating physician found that there is no treatment needed at this time but, "if the patient is exposed again to mold and she has flare up of various symptoms," she may require additional doctor visits. (Exh.1, August 12, 2020, Ronald Zlotolow M.D., Primary Treating Physician Report, p. 5.) In addition, the panel qualified medical evaluator recommended applicant be provided with an air purifier on an industrial basis.3 (Exh. A, June 10, 2020, Marc Meth, M.D., Panel Qualified Medical Evaluation, p. 11.) These reports, taken together, establish that applicant may require future medical care as a result of her industrial injuries. Defendant is required to provide medical treatment that complies with Section 4600. Applicant need not establish that she will certainly need future medical care for an award of future medical care to issue. It is sufficient that there is substantial medical evidence that future medical care may be needed.

The facts that decided it

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

Primary treating physician found no treatment needed at this time but possible future treatment if exposed to mold flare-up.

Favours Applicant prevailed

Supports finding that applicant may require future medical care.

From the decision · page 2In this case, applicant's primary treating physician found that there is no treatment needed at this time but, "if the patient is exposed again to mold and she has flare up of various symptoms," she may require additional doctor visits. (Exh.1, August 12, 2020, Ronald Zlotolow M.D., Primary Treating Physician Report, p. 5.) In addition, the panel qualified medical evaluator recommended applicant be provided with an air purifier on an industrial basis.3 (Exh. A, June 10, 2020, Marc Meth, M.D., Panel Qualified Medical Evaluation, p. 11.) These reports, taken together, establish that applicant may require future medical care as a result of her industrial injuries. Defendant is required to provide medical treatment that complies with Section 4600. Applicant need not establish that she will certainly need future medical care for an award of future medical care to issue. It is sufficient that there is substantial medical evidence that future medical care may be needed.

Panel qualified medical evaluator recommended applicant be provided with an air purifier on an industrial basis.

Favours Applicant prevailed

Indicates need for future medical care as part of treatment for industrial injuries.

From the decision · page 2In this case, applicant's primary treating physician found that there is no treatment needed at this time but, "if the patient is exposed again to mold and she has flare up of various symptoms," she may require additional doctor visits. (Exh.1, August 12, 2020, Ronald Zlotolow M.D., Primary Treating Physician Report, p. 5.) In addition, the panel qualified medical evaluator recommended applicant be provided with an air purifier on an industrial basis.3 (Exh. A, June 10, 2020, Marc Meth, M.D., Panel Qualified Medical Evaluation, p. 11.) These reports, taken together, establish that applicant may require future medical care as a result of her industrial injuries. Defendant is required to provide medical treatment that complies with Section 4600. Applicant need not establish that she will certainly need future medical care for an award of future medical care to issue. It is sufficient that there is substantial medical evidence that future medical care may be needed.

The rules the panel named

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

Labor Code section 46002

An award of medical care reasonably required to cure or relieve the injured employee of the effects of his or her injury is not an award of a specific treatment.

Requires employer to provide reasonable medical treatment to cure or relieve effects of industrial injury.

From the decision · page 1An award of medical care "reasonably required to cure or relieve the injured employee of the effects of his or her injury" is not an award of a specific treatment. Labor Code section 46002

Labor Code sections 4610, 4062(b), 4610.5; Dubon II (2014) 79 Cal.Comp.Cases 1298

Employers must establish a utilization review (UR) process for treatment requests; if UR decision is untimely, Appeals Board may determine medical necessity; if timely, IMR is sole review vehicle.

Explains process for determining reasonableness and necessity of specific treatment requests.

From the decision · page 2Whether a specific treatment is reasonable and necessary is typically determined through utilization review (UR). Employers are required to establish a UR process for treatment requests received from physicians. (Lab. Code, § 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236.) In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298, 1299 (Appeals Bd. en banc) (Dubon II), the Appeals Board held that if a UR decision is untimely, the UR decision is invalid and not subject to independent medical review (IMR). The Dubon II decision further held that the Appeals Board has jurisdiction to determine whether a UR decision is timely. (Id.) If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) However, "where a UR decision is timely, IMR is the sole vehicle for reviewing the UR physician's expert opinion regarding the medical necessity of a proposed treatment." (Id. at pp. 1310-1311; see also Lab. Code, § 4062(b), 4610.5.)

ADJ12973118 · May 17, 2023

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

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The rules the panel named

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