ADJ16340745 · August 7, 2026

The WCA found that defendant neglected to provide reasonable medical care through the MPN and failed to provide required notice of rights, enabling applicant to self-procure surgery which was reasonable and necessary, thus awarding reimbursement.

From the decision · page 1Defendant City and County of San Francisco seeks reconsideration of the Findings of Fact and Award (F&A) issued by a workers’ compensation arbitrator (WCA) on April 27, 2026. In that decision, the WCA found, in relevant part, that applicant could self-procure medical treatment without going through the employer’s Medical Provider Network (MPN) or making a demand on defendant for the treatment, and that the disc replacement surgery that applicant self-procured, was reasonable and necessary, and should be reimbursed by defendant, based upon the medical report of Independent Medical Evaluator (IME) Steven Feinberg, M.D.

Defendant failed to provide required notice of rights under the MPN to applicant.

Favours Applicant prevailed

This failure was found to be neglect or refusal to provide medical treatment, enabling applicant to self-procure surgery.

From the decision · page 9or of his right under section 4613(c) to dispute an MPN diagnosis and to obtain second and third opinions. The record is further lacking proof applicant was apprised of his ability to avail himself of the MPN Independent Medical Review process (IMR) as set forth in section 4616.4 after the opinion of a third physician regarding a treatment or diagnostic service that remains in dispute. (Lab. Code, § 4616.4(b).) Further, the sole notice to applicant proffered by defendant at trial is the April 3, 2018 Notice Regarding Permanent Disability Benefits Denial. This notice apprised applicant of his right to a QME to dispute the disability findings of Dr. Bible in his report of April 2, 2018, but provided no guidance on how he was supposed to obtain additional medical treatment within the MPN in the event of an exacerbation. Information about how to access medical treatment, how to choose and change physicians, how to obtain independent medical review, and, thus, how to generally and specifically "use" the MPN, are all crucial to the provision of reasonable medical treatment. The record reflects that when applicant returned to Kaiser in September 2018 for a flare up of his back, he discussed his condition with Scott Edward Pinner, M.D., and requested additional studies and a new MRI and X-rays for his back.

Applicant self-procured disc replacement surgery in Germany after being verbally denied treatment within the MPN.

Favours Applicant prevailed

The surgery was found reasonable and necessary, supporting reimbursement.

From the decision · page 10fusion.” Dr. Bains further noted in his report that “[p]atient has been informed that this technology in Germany will not be approved by KP.” (Id. at Bates stamp 0479.) While applicant’s treating physician, Dr. Pinner, and consulting physicians Dr. Yacob and Bains advised applicant they would not recommend a disc replacement, applicant was unaware of his rights to the IMR process to dispute those determinations. In fact, Dr. Bains went so far as advising applicant that Kaiser (aka KP) would not approve of the technology. Shortly after this visit, on March 21, 2019, applicant decided to self-procure disc replacement surgery in Germany. In this case, the WCA found that defendant failed to tender reasonable medical care through the MPN and further failed to provide required notice to applicant of his rights under the MPN.

Disc replacement surgery was a reasonable alternative to back fusion and was successful, supporting reimbursement for self-procured treatment.

Dr. Feinberg opined that the disc replacement surgery was reasonable and necessary based on the applicant's successful recovery.

From the decision · page 537:5-8.) On March 13, 2026, the parties submitted, and WCA Kahn approved, the parties’ Stipulations for 16% permanent disability to the lumbar spine, with future medical care, based upon the reporting of IME Dr. Feinberg’s report dated September 27, 2021. (Stipulations, 3/13/26, pp. 8-9.) On April 27, 2026, the WCA issued the F&A. III. DISCUSSION An employer or its insurer is obligated to provide all medical treatment "that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." (Lab. Code, § 4600(a).) "In the case of his or her neglect or refusal reasonably to do so, the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment." (Lab. Code, § 4600(a).) An employer will not be relieved of the duty to furnish medical care absent good cause, and section 4600 has been liberally interpreted in favor of the employee's right to obtain reimbursement. [Citations.] (Knight v. United Parcel Service (2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc.)

Lab. Code, § 4600(a)

An employer or insurer must provide all medical treatment reasonably required to cure or relieve the injured worker from the effects of injury, and if neglect or refusal occurs, the employer is liable for reasonable expenses incurred by the employee for treatment.

The WCA applied this standard to find defendant neglected to provide reasonable medical care, enabling self-procurement and reimbursement.

From the decision · page 537:5-8.) On March 13, 2026, the parties submitted, and WCA Kahn approved, the parties’ Stipulations for 16% permanent disability to the lumbar spine, with future medical care, based upon the reporting of IME Dr. Feinberg’s report dated September 27, 2021. (Stipulations, 3/13/26, pp. 8-9.) On April 27, 2026, the WCA issued the F&A. III. DISCUSSION An employer or its insurer is obligated to provide all medical treatment "that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." (Lab. Code, § 4600(a).) "In the case of his or her neglect or refusal reasonably to do so, the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment." (Lab. Code, § 4600(a).) An employer will not be relieved of the duty to furnish medical care absent good cause, and section 4600 has been liberally interpreted in favor of the employee's right to obtain reimbursement. [Citations.] (Knight v. United Parcel Service (2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc.)

Lab. Code, §§ 4600(c), 4616 et seq.

If an employer has an MPN, it is only liable for treatment by a physician within the MPN, but neglect or refusal to provide necessary treatment allows employee to self-procure treatment at employer's expense.

The WCA found defendant neglected to provide treatment through the MPN, allowing applicant to self-procure surgery.

Lab. Code, §§ 3202.5; 5705

Burden of proof rests on the party holding the affirmative of the issue; employer bears burden to prove notice of rights under MPN.

The WCA applied this to find defendant failed to prove notice was given to applicant.

From the decision · page 7employee to be treated by his or her personal physician with respect to an injury occurring during that failure." (Lab. Code, § 3550(e).) Additional notice obligations are triggered at the time of an industrial injury. Within one working day of receiving notice of injury, the employer must provide the employee with a claim form, information about benefits available to the employee and the workers' compensation process. (Lab. Code, §§ 5401 through 5402; Cal. Code Regs., tit. 8, §§ 9810 through 9812; see also Lab. Code, §§ 138.3 and 138.4.) The failure to properly provide such notice may toll the statute of limitations. (Reynolds v. Workers' Comp. Appeals Bd. (1974) 12 Cal.3d 726 [39 Cal.Comp.Cases 768]; Buena Ventura Gardens v. Workers' Comp. Appeals Bd. (Novak) (1975) 49 Cal.App.3d 410 [40 Cal.Comp.Cases 434].) In the context of the provision of medical treatment, failure to provide other required notices may be a neglect or refusal to provide medical treatment that renders the employer or insurer liable for self-procured medical treatment. (Knight, supra, at p. 1434.) With regard to notice, the burden of proof rests on the party holding the affirmative of the issue. (Lab. Code, § 5705.) In the event of a dispute about whether the injured worker was provided notice of rights under an MPN, the employer carries the burden of proof.

Lab. Code, § 3550(e)

The employer is liable for treatment by the employee's personal physician if the employer fails to provide treatment.

Supports the finding that defendant's failure to provide treatment led to applicant's self-procurement.

From the decision · page 7employee to be treated by his or her personal physician with respect to an injury occurring during that failure." (Lab. Code, § 3550(e).) Additional notice obligations are triggered at the time of an industrial injury. Within one working day of receiving notice of injury, the employer must provide the employee with a claim form, information about benefits available to the employee and the workers' compensation process. (Lab. Code, §§ 5401 through 5402; Cal. Code Regs., tit. 8, §§ 9810 through 9812; see also Lab. Code, §§ 138.3 and 138.4.) The failure to properly provide such notice may toll the statute of limitations. (Reynolds v. Workers' Comp. Appeals Bd. (1974) 12 Cal.3d 726 [39 Cal.Comp.Cases 768]; Buena Ventura Gardens v. Workers' Comp. Appeals Bd. (Novak) (1975) 49 Cal.App.3d 410 [40 Cal.Comp.Cases 434].) In the context of the provision of medical treatment, failure to provide other required notices may be a neglect or refusal to provide medical treatment that renders the employer or insurer liable for self-procured medical treatment. (Knight, supra, at p. 1434.) With regard to notice, the burden of proof rests on the party holding the affirmative of the issue. (Lab. Code, § 5705.) In the event of a dispute about whether the injured worker was provided notice of rights under an MPN, the employer carries the burden of proof.

Applicant was unaware of his rights to the IMR process to dispute medical treatment denials and was verbally denied requested treatment by treating and consulting physicians.

From the decision · page 10fusion.” Dr. Bains further noted in his report that “[p]atient has been informed that this technology in Germany will not be approved by KP.” (Id. at Bates stamp 0479.) While applicant’s treating physician, Dr. Pinner, and consulting physicians Dr. Yacob and Bains advised applicant they would not recommend a disc replacement, applicant was unaware of his rights to the IMR process to dispute those determinations. In fact, Dr. Bains went so far as advising applicant that Kaiser (aka KP) would not approve of the technology. Shortly after this visit, on March 21, 2019, applicant decided to self-procure disc replacement surgery in Germany. In this case, the WCA found that defendant failed to tender reasonable medical care through the MPN and further failed to provide required notice to applicant of his rights under the MPN.

Defendant failed to provide required notice of rights under the MPN, including how to access medical treatment and dispute processes.

From the decision · page 9or of his right under section 4613(c) to dispute an MPN diagnosis and to obtain second and third opinions. The record is further lacking proof applicant was apprised of his ability to avail himself of the MPN Independent Medical Review process (IMR) as set forth in section 4616.4 after the opinion of a third physician regarding a treatment or diagnostic service that remains in dispute. (Lab. Code, § 4616.4(b).) Further, the sole notice to applicant proffered by defendant at trial is the April 3, 2018 Notice Regarding Permanent Disability Benefits Denial. This notice apprised applicant of his right to a QME to dispute the disability findings of Dr. Bible in his report of April 2, 2018, but provided no guidance on how he was supposed to obtain additional medical treatment within the MPN in the event of an exacerbation. Information about how to access medical treatment, how to choose and change physicians, how to obtain independent medical review, and, thus, how to generally and specifically "use" the MPN, are all crucial to the provision of reasonable medical treatment. The record reflects that when applicant returned to Kaiser in September 2018 for a flare up of his back, he discussed his condition with Scott Edward Pinner, M.D., and requested additional studies and a new MRI and X-rays for his back.