Medical treatment, UR and IMR

What the Appeals Board did with this

Newest released decisions that turned on this issue. Each quotes the passage it turned on and links to the official PDF. Litigated tail — not a win rate, not a settlement value.

• ADJ11672907 · 2026-09-24 · Salinas District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.11Taking all the above into consideration and given that the medical record is lacking with respect to the issue of applicant’s psyche claim, we continue to believe that good cause exists for the issuance of an additional QME panel.

  The medical record was insufficient on the psyche claim, and Dr. Feinberg, the orthopedic AME, recommended a psyche evaluation. The WCAB found good cause for an additional QME panel to address the psyche claim.

  Official decision · page 11 →
• ADJ11775583 · 2026-09-23 · Van Nuys District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.17Because the February 16, 2021 UR decision made clear that interim home health care services would be necessary until a permanent solution could be found to address applicant’s home health needs, and because the record reflects no efforts to reach such resolution, we agree with the WCJ’s decision to enforce the February 16, 2021 UR decision. However, we also observe that the March 16, 2021 RFA did not present a previously unresolved question of medical necessity, and as such, we do not concur with the WCJ’s burden shifting analysis. Accordingly, we will amend Finding of Fact No. 3 to reflect that the UR decision of February 16, 2021 determined that the nature of applicant’s condition requires the provision of continued home health care services until a more specific, permanent solution is found. We will then amend the Order to reflect that defendant must continue to provide the specified home health care services, six hours per day, five days per week, until such time as the parties can demonstrate reasonable efforts to identify and implement a permanent solution to applicant’s need for home health care services.

  The WCAB found that the February 16, 2021 UR decision established the need for continued home health care services until a permanent solution is found, and that the WCAB has jurisdiction over the dispute as the March 16, 2021 RFA did not present a new question of medical necessity triggering IMR jurisdiction.

  Official decision · page 17 →
• ADJ19686963 · 2026-09-21 · Redding District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.1316.) In his Opinion on Decision, the PWCJ states “Dr. Richman was silent on the question of treatment” and that Dr. Lo’s opinion on medical care was issued before applicant reached maximum medical improvement (MMI). (Opinion on Decision, p. 9.) The inference raised by the PWCJ is that the applicant may no longer require medical care after having reached MMI status. While we acknowledge the effort and quality put into the F&A, such an inference is not appropriate in this case. Given the severe nature of applicant’s injury, the recommendation for further treatment by two treating physicians, and the PQME’s recommendation issued after achieving MMI that applicant should undergo “octopus telemetry,” an award of medical care is reasonable and well supported. (Id. at p. 462.) Moreover, when applicant seeks a particular treatment modality at defendant’s expense, applicant must still demonstrate by way of medical evidence that the particular treatment sought is reasonable and necessary. (See Lab. Code, §§ 4600, 4610 et seq.) We therefore find that applicant is entitled to medical care and to award medical care.

  Given the severe nature of injury and recommendations by treating physicians and PQME, medical care award is supported and granted.

  Official decision · page 13 →
• ADJ21943588 · 2026-09-01 · Pomona District OfficeMedical treatment / UR / IMRdefendant prevailed

  Determinative passage · p.5Applicant also contends that because the notice of denial was defective, the defective notice invalidates the QME panel. As noted above, a denial notice is not required to contain a date of injury (Cal. Code Regs., tit. 8, § 9812, subd. (g)) and the transposition of “0” and “3” was insufficient to render the notice invalid, especially given the other identifying information and the fact that no evidence was presented that there was any other outstanding claim between the parties. Furthermore, a decision issued by the Appeals Board may address a hybrid of both threshold and interlocutory issues. If a party challenges a hybrid decision, the petition seeking relief is treated as a petition for reconsideration because the decision resolves a threshold issue. Here, as noted above, the determination that the section 5402(b) presumption did not apply is a final order. However, when interlocutory orders are being challenged, we evaluate these issues under the removal standard. (See Capital Builders Hardware, Inc. v. Workers’ Comp. Appeals Bd. (Gaona) (2016) 5 Cal.App.5th 658 [81 Cal.Comp.Cases 1122].) We note that orders of the WCAB regarding development of the record are interlocutory in nature.

  The denial notice was not defective despite a typographical error, and the orthopedic QME panel requested by defendant was valid. The applicant failed to raise the issue properly or provide evidence to support a chiropractic panel request.

  Official decision · page 5 →
• ADJ4162830 · 2026-08-14 · Marina del Rey District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.10749.) Among the methods described for challenging a rating obtained under the PDRS is establishing that “the injury to the employee impairs his or her rehabilitation, and for that reason, the employee’s diminished future earning capacity is greater than reflected in the employee’s scheduled rating.” (Ogilvie v. Workers’ Comp. Appeals Bd. (2011) 197 Cal.App.4th 1262, 1274 [76 Cal.Comp.Cases 624].) Our opinion in Nunes I made clear that “[t]he same considerations used to evaluate whether a medical expert’s opinion constitutes substantial evidence are equally applicable to vocational reporting … [i]n order to constitute substantial evidence, a vocational expert’s opinion must detail the history and evidence in support of its conclusions, as well as ‘how and why’ any specific condition or factor is causing permanent disability.” (Nunes I, supra, at p. 751.) Based upon our review of the evidentiary record, including the vocational reports in this matter, we believe that VE Wilson’s opinions are substantial evidence and that applicant has successfully rebutted the PDRS. Wilson completed a full assessment, took a detailed history, and provided evidence and reasoning in support of her conclusions.

  The WCJ found the vocational expert’s reports to be substantial evidence supporting the applicant’s inability to return to work and rebuttal of the PDRS, considering all medical records and apportionment.

  Official decision · page 10 →
• ADJ9213906 · 2026-08-11 · Van Nuys District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.8(Cal. Code Regs., tit. 8, § 10786(e) and (f).) Here, there is no evidence in the record that defendant objected to cost petitioner’s invoices or issued any EORs. At time of trial, defendant offered no exhibit evidence or witness testimony about its timely compliant objections or EORs in response to cost petitioner’s invoices. Accordingly, under section 4622(a), defendant has waived their objections to cost petitioner’s invoices, and they owe the bills, penalties of 10 percent, and 7 percent per annum interest. Furthermore, the WCJ’s order of payment per fee schedule is incorrect. Specifically, under WCAB Rule 10786(f), the fee schedule applies when defendant has sent EORs. We also note that the order to bill review is also not appropriate given that defendant failed to submit evidence that it issued timely compliant objections or EORs. (Lab.

  Defendant failed to issue timely and compliant objections or Explanations of Review (EORs) to cost petitioner's invoices as required by Labor Code section 4622(a) and WCAB Rule 10786(e), resulting in waiver of objections and entitlement to payment, penalties, and interest for cost petitioner.

  Official decision · page 8 →
• ADJ16340745 · 2026-08-07 · San Francisco District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.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.

  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.

  Official decision · page 1 →
• ADJ21567804 · 2026-07-20 · Pomona District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.7Here, the report is not signed by anyone other than the nurse practitioner. Applicant provided unrebutted testimony that no physician other than the nurse practitioner and a physician

  The nurse practitioner's report was not signed by a physician and thus invalid as a release from care; a nurse practitioner cannot be designated as a primary treating physician under Labor Code section 3209.10; therefore, the applicant is entitled to designate a new primary treating physician and continue medical treatment.

  Official decision · page 7 →