ADJ18067229 · July 10, 2025

The WCAB panel found that the defendant did not meet the burden of proof to show a change in applicant's medical condition or circumstances to justify discontinuing ongoing home health care, and thus denied the petition for reconsideration.

From the decision · page 1We have considered the allegations of the Petition for Reconsideration and the contents of the report 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, which we adopt and incorporate, and for the additional reasons given below, we will deny reconsideration.

Defendant did not present substantial medical evidence of a change in applicant's medical condition or circumstances since prior authorization of home health care on May 24, 2024.

Favours Applicant prevailed

This failure meant the defendant did not meet the burden to justify discontinuing ongoing home health care, leading to denial of the petition.

From the decision · page 11Quite simply, Defendant did not present any substantial medical evidence to demonstrate a change in the Applicant's medical condition or circumstances. The various "chart" notes and other reports with reference to Applicant doing better, going to treatment outside the house, and that the home health aide's activities involving house cleaning and pet care, are not substantial medical evidence. Nothing in Defendant's offered medical reports identify any discussion of any change of medical condition or circumstances of the Applicant.

Recommended more home health care aide 5 days/week for 12 weeks based on office visit and ambulatory referral reports.

The opinion supports the ongoing need for home health care services, which was a central issue in the reconsideration petition.

From the decision · page 8On 8/26/2024, UR denied the request for continued home health care based on Applicant attending outpatient PT and OT, having support of family members, and the services being requested were non-skilled services to care for his pets and housekeeping." (See Joint Exhibit X, pages 1, 14). The above discussed Skilled Nurse Visit reports as well as the subsequent Skilled Nurse Visit reports of 10/17/2024, 10/25/2024, and 10/30/2024, documented Applicant's continued need for home health care, in general, due to mobility issues alone. (Applicant's Exhibits 19, 21, 22, 26 § 28). PTP Dr. Tran also recommended more home health care aide 5 days/wk for 12 weeks pursuant to his Office Visit and Ambulatory Referral reports, both dated 10/1/2024, and his RFA of 10/3/2025. (Joint Exhibit Y, page 5; Applicant's Exhibits 23, 24).

California Labor Code

Labor Code section 5909

Governs the timing and notice requirements for petitions for reconsideration before the WCAB.

From the decision · page 1Former Labor Code section 5909 provided that a petition for reconsideration was deemed denied unless the Appeals Board acted on the petition within 60 days from the date of filing. (Lab. Code, § 5909.) Effective July 2, 2024, Labor Code section 5909 was amended to state in relevant part that:

CA-WCAB Significant Panel Decision

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

Establishes that defendants must show a change in circumstances to justify a new utilization review for ongoing care previously authorized.

From the decision · page 2In addition to the reasons set forth in the WCJ's Report, we note that in this case, unlike in Allied Signal Aero. v. Workers' Comp. Appeals Bd. (Wiggs) (2019) 35 Cal.App.5th 1077 [86 Cal.Comp.Cases 367], the issue is not whether defendant agreed to waive utilization review or refer it to a nurse for alternative dispute resolution on a one-time basis. We do not find any waiver by defendants, nor would we go so far as to characterize the provided treatment in this case as a "stipulation" between the parties. Instead, the issue in the present case is whether ongoing care, which had already been certified as reasonable and necessary through the utilization review process on May 24, 2024 and provided by defendants, should have been sent for a redundant subsequent utilization review absent any evidence that material facts had changed. The WCJ correctly applied the reasoning in Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910 (Appeals Board Significant Panel Decision), and National Cement Co. v. Workers' Comp. Appeals

California Court of Appeal

Allied Signal Aero. v. Workers' Comp. Appeals Bd. (Wiggs) (2019) 35 Cal.App.5th 1077

Clarifies limits on utilization review and stipulations for ongoing care; distinguished in this case as no waiver or stipulation for ongoing care was found.

From the decision · page 2In addition to the reasons set forth in the WCJ's Report, we note that in this case, unlike in Allied Signal Aero. v. Workers' Comp. Appeals Bd. (Wiggs) (2019) 35 Cal.App.5th 1077 [86 Cal.Comp.Cases 367], the issue is not whether defendant agreed to waive utilization review or refer it to a nurse for alternative dispute resolution on a one-time basis. We do not find any waiver by defendants, nor would we go so far as to characterize the provided treatment in this case as a "stipulation" between the parties. Instead, the issue in the present case is whether ongoing care, which had already been certified as reasonable and necessary through the utilization review process on May 24, 2024 and provided by defendants, should have been sent for a redundant subsequent utilization review absent any evidence that material facts had changed. The WCJ correctly applied the reasoning in Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910 (Appeals Board Significant Panel Decision), and National Cement Co. v. Workers' Comp. Appeals

Applicant's credible testimony about ongoing need for assistance with transfers, colostomy bag, medication, meals, doctor visits, and chores.

From the decision · page 8At the Trial, Applicant credibly testified that he still needed transfer assistance, colostomy bag assistance, medication assistance, meal prep assistance, doctor evaluation assistance and assistance with chores. He confirmed that his current treatment is outside the home, and transportation is provided. Applicant testified that he can mostly only move himself in his wheelchair in a backwards direction. (MOH/SOE, 2/3/2025, page 2, line 25, page 3, lines 1 § 18).

Home health care skilled nurse visit reports documenting continued need due to mobility issues.

From the decision · page 8On 8/26/2024, UR denied the request for continued home health care based on Applicant attending outpatient PT and OT, having support of family members, and the services being requested were non-skilled services to care for his pets and housekeeping." (See Joint Exhibit X, pages 1, 14). The above discussed Skilled Nurse Visit reports as well as the subsequent Skilled Nurse Visit reports of 10/17/2024, 10/25/2024, and 10/30/2024, documented Applicant's continued need for home health care, in general, due to mobility issues alone. (Applicant's Exhibits 19, 21, 22, 26 § 28). PTP Dr. Tran also recommended more home health care aide 5 days/wk for 12 weeks pursuant to his Office Visit and Ambulatory Referral reports, both dated 10/1/2024, and his RFA of 10/3/2025. (Joint Exhibit Y, page 5; Applicant's Exhibits 23, 24).