What the panel ordered
Joint Findings and Order rescinded; matter returned to trial level for further proceedings and decision by the WCJ.
Defendant sought reconsideration of the WCJ's Joint Findings and Order regarding medical treatment liens. The WCAB granted reconsideration, rescinded the order, and remanded for further proceedings.
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.
The WCJ's reliance on Dr. Paul's March 10, 2009 report was insufficient to establish the reasonableness and necessity of the medical treatment under the MTUS or to rebut the MTUS by a preponderance of scientific evidence. The record did not clearly support the liens as reasonable and necessary, and further proceedings are required.
From the decision · page 6Here, the WCJ found that Dr. Paul's March 10, 2009 Report satisfied lien claimants' burden of proof that their medical treatments were reasonable and necessary. Based on the record before us, it is not entirely clear if this report satisfies either lien claimant's burden of proof. A review of Dr. Paul's March 10, 2009 Report reveals no mention of the MTUS, and Dr. Paul did not present "a preponderance of scientific evidence" to justify a variance from treatment per the MTUS. Additionally, Dr. Paul did not review any medical records for his March 10, 2009 report, and he did not discuss any of applicant's prior medical treatment. Thus, it is unclear how Dr. Paul's March 10, 2009 report could be used to evaluate or justify applicant's medical treatment prior to March 10, 2009, as reasonable and necessary. Furthermore, it is unclear how Dr. Paul's report of March 10, 2009, may be the basis for the reasonableness and necessity of medical treatment
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Dr. Paul's March 10, 2009 report did not mention the MTUS, did not present scientific evidence to justify a variance, and did not review or discuss prior medical treatment.
Favours Defendant prevailed
This deficiency meant the report could not be relied upon to establish the reasonableness and necessity of the medical treatment liens, leading to remand.
From the decision · page 6Here, the WCJ found that Dr. Paul's March 10, 2009 Report satisfied lien claimants' burden of proof that their medical treatments were reasonable and necessary. Based on the record before us, it is not entirely clear if this report satisfies either lien claimant's burden of proof. A review of Dr. Paul's March 10, 2009 Report reveals no mention of the MTUS, and Dr. Paul did not present "a preponderance of scientific evidence" to justify a variance from treatment per the MTUS. Additionally, Dr. Paul did not review any medical records for his March 10, 2009 report, and he did not discuss any of applicant's prior medical treatment. Thus, it is unclear how Dr. Paul's March 10, 2009 report could be used to evaluate or justify applicant's medical treatment prior to March 10, 2009, as reasonable and necessary. Furthermore, it is unclear how Dr. Paul's report of March 10, 2009, may be the basis for the reasonableness and necessity of medical treatment
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.
Dr. Paul's March 10, 2009 report did not mention the MTUS, did not present scientific evidence to justify a variance from the MTUS, and did not review prior medical records or discuss prior treatment. The report was insufficient to establish the reasonableness and necessity of the medical treatment for the liens.
The WCAB found Dr. Paul's report did not satisfy the burden of proof for the liens' reasonableness and necessity.
From the decision · page 6Here, the WCJ found that Dr. Paul's March 10, 2009 Report satisfied lien claimants' burden of proof that their medical treatments were reasonable and necessary. Based on the record before us, it is not entirely clear if this report satisfies either lien claimant's burden of proof. A review of Dr. Paul's March 10, 2009 Report reveals no mention of the MTUS, and Dr. Paul did not present "a preponderance of scientific evidence" to justify a variance from treatment per the MTUS. Additionally, Dr. Paul did not review any medical records for his March 10, 2009 report, and he did not discuss any of applicant's prior medical treatment. Thus, it is unclear how Dr. Paul's March 10, 2009 report could be used to evaluate or justify applicant's medical treatment prior to March 10, 2009, as reasonable and necessary. Furthermore, it is unclear how Dr. Paul's report of March 10, 2009, may be the basis for the reasonableness and necessity of medical treatment
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code §§ 4600, 4604.5, 5307.27; 8 CCR 9792.5.5
Lien claimants bear the burden of proof to establish that the medical treatment was reasonable and necessary to cure or relieve the effects of the industrial injury, consistent with the MTUS or rebutted by a preponderance of scientific medical evidence.
The WCAB applied these standards to determine that the evidence did not establish the reasonableness and necessity of the medical treatment liens, requiring remand for further proceedings.
From the decision · page 6provided was reasonable and necessary to cure applicant from the effects of her industrial injury. (State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 237- 238 [73 Cal.Comp.Cases 981]; Tito Torres v. AJC Sandblasing (2012) 77 Cal.Comp.Cases 1113, 1121 [2012 Cal. Wrk. Comp. LEXIS 160] (Appeals Board en Banc).) To determine whether lien claimants have satisfied their burden of proof, the parties, first, need to ascertain whether there were MTUS guidelines, which covered their medical services at the time their services were provided.
What proof carried it
The evidence the panel weighed, by kind.
Dr. Paul's March 10, 2009 report did not address the MTUS, did not present scientific evidence to justify a variance, and did not review or discuss prior medical treatment.
From the decision · page 6Here, the WCJ found that Dr. Paul's March 10, 2009 Report satisfied lien claimants' burden of proof that their medical treatments were reasonable and necessary. Based on the record before us, it is not entirely clear if this report satisfies either lien claimant's burden of proof. A review of Dr. Paul's March 10, 2009 Report reveals no mention of the MTUS, and Dr. Paul did not present "a preponderance of scientific evidence" to justify a variance from treatment per the MTUS. Additionally, Dr. Paul did not review any medical records for his March 10, 2009 report, and he did not discuss any of applicant's prior medical treatment. Thus, it is unclear how Dr. Paul's March 10, 2009 report could be used to evaluate or justify applicant's medical treatment prior to March 10, 2009, as reasonable and necessary. Furthermore, it is unclear how Dr. Paul's report of March 10, 2009, may be the basis for the reasonableness and necessity of medical treatment
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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.
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