What the panel ordered
Petition for reconsideration is denied as to ADJ11143930 and dismissed as to ADJ11143932.
Defendant filed a timely verified petition for reconsideration of the WCJ's finding that the IMR determination was the result of a plainly erroneous finding of fact; the WCAB reviewed the record and adopted the WCJ's report.
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 IMR determination incorrectly stated that Dr. Rothi's June 30, 2022 RFA was for six months of continuous home healthcare, when in fact the RFA made no mention of six months and the PR-2 report indicated a follow-up appointment was scheduled for August 10, 2022. This was a plainly erroneous finding of fact, not subject to expert opinion.
From the decision · page 5The September 7, 2022 Independent Medical Review determination of the administrative director clearly asserts as its rational the statement that Dr. Rothi's June 30, 2022 RFA was for "home health aide assistance four hours a day, two days a week for six months for bathing, house mobility, and hygiene (failed back surgery, bilateral knee, bilateral shoulder pain) quantity in months #6". (Exhibit 16, IMR Determination, dated September 7, 2022, page 2). The rationale continued on page 3 indicating that "the request is for six months of continuous home healthcare without evaluating for compliance and the continued need for these services." This is factually incorrect. Dr. Rothi's June 30, 2022 RFA makes no mention of six months. It requests home health assistance for "4 hours a day, X 2 days a week PRN". Furthermore Dr. Rothi's accompanying PR- 2 report clearly indicates a follow-up appointment scheduled for August 10, 2022. (See applicant's Exhibit 21, PR-2 reports by Dr. Rothi up through September 20, 2022, pages 8 through 11). On this basis it is clear that the determination of the administrative director was the result of a plainly
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Dr. Rothi's June 30, 2022 RFA did not request six months of continuous home healthcare, but rather '4 hours a day, X 2 days a week PRN', and the PR-2 report scheduled a follow-up for August 10, 2022.
Favours Applicant prevailed
This fact directly contradicted the IMR determination's rationale and was the basis for finding a plainly erroneous finding of fact.
From the decision · page 5The September 7, 2022 Independent Medical Review determination of the administrative director clearly asserts as its rational the statement that Dr. Rothi's June 30, 2022 RFA was for "home health aide assistance four hours a day, two days a week for six months for bathing, house mobility, and hygiene (failed back surgery, bilateral knee, bilateral shoulder pain) quantity in months #6". (Exhibit 16, IMR Determination, dated September 7, 2022, page 2). The rationale continued on page 3 indicating that "the request is for six months of continuous home healthcare without evaluating for compliance and the continued need for these services." This is factually incorrect. Dr. Rothi's June 30, 2022 RFA makes no mention of six months. It requests home health assistance for "4 hours a day, X 2 days a week PRN". Furthermore Dr. Rothi's accompanying PR- 2 report clearly indicates a follow-up appointment scheduled for August 10, 2022. (See applicant's Exhibit 21, PR-2 reports by Dr. Rothi up through September 20, 2022, pages 8 through 11). On this basis it is clear that the determination of the administrative director was the result of a plainly
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. Rothi's June 30, 2022 RFA requested home health assistance for '4 hours a day, X 2 days a week PRN' and did not mention six months of continuous care. The PR-2 report indicated a follow-up appointment was scheduled for August 10, 2022.
The WCJ and WCAB found that the IMR determination mischaracterized Dr. Rothi's RFA, which did not request six months of continuous care.
From the decision · page 5The September 7, 2022 Independent Medical Review determination of the administrative director clearly asserts as its rational the statement that Dr. Rothi's June 30, 2022 RFA was for "home health aide assistance four hours a day, two days a week for six months for bathing, house mobility, and hygiene (failed back surgery, bilateral knee, bilateral shoulder pain) quantity in months #6". (Exhibit 16, IMR Determination, dated September 7, 2022, page 2). The rationale continued on page 3 indicating that "the request is for six months of continuous home healthcare without evaluating for compliance and the continued need for these services." This is factually incorrect. Dr. Rothi's June 30, 2022 RFA makes no mention of six months. It requests home health assistance for "4 hours a day, X 2 days a week PRN". Furthermore Dr. Rothi's accompanying PR- 2 report clearly indicates a follow-up appointment scheduled for August 10, 2022. (See applicant's Exhibit 21, PR-2 reports by Dr. Rothi up through September 20, 2022, pages 8 through 11). On this basis it is clear that the determination of the administrative director was the result of a plainly
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code § 4610.6(h)(5)
An IMR determination may be set aside by clear and convincing evidence that it was the result of an erroneous finding of fact not subject to expert opinion.
The Board found the IMR determination was based on a plainly erroneous finding of fact, not subject to expert opinion, because the RFA did not request six months of care.
From the decision · page 5The September 7, 2022 Independent Medical Review determination of the administrative director clearly asserts as its rational the statement that Dr. Rothi's June 30, 2022 RFA was for "home health aide assistance four hours a day, two days a week for six months for bathing, house mobility, and hygiene (failed back surgery, bilateral knee, bilateral shoulder pain) quantity in months #6". (Exhibit 16, IMR Determination, dated September 7, 2022, page 2). The rationale continued on page 3 indicating that "the request is for six months of continuous home healthcare without evaluating for compliance and the continued need for these services." This is factually incorrect. Dr. Rothi's June 30, 2022 RFA makes no mention of six months. It requests home health assistance for "4 hours a day, X 2 days a week PRN". Furthermore Dr. Rothi's accompanying PR- 2 report clearly indicates a follow-up appointment scheduled for August 10, 2022. (See applicant's Exhibit 21, PR-2 reports by Dr. Rothi up through September 20, 2022, pages 8 through 11). On this basis it is clear that the determination of the administrative director was the result of a plainly
What proof carried it
The evidence the panel weighed, by kind.
The actual language of Dr. Rothi's June 30, 2022 RFA and the PR-2 report, which did not request six months of continuous home healthcare and scheduled a follow-up for August 10, 2022.
From the decision · page 5The September 7, 2022 Independent Medical Review determination of the administrative director clearly asserts as its rational the statement that Dr. Rothi's June 30, 2022 RFA was for "home health aide assistance four hours a day, two days a week for six months for bathing, house mobility, and hygiene (failed back surgery, bilateral knee, bilateral shoulder pain) quantity in months #6". (Exhibit 16, IMR Determination, dated September 7, 2022, page 2). The rationale continued on page 3 indicating that "the request is for six months of continuous home healthcare without evaluating for compliance and the continued need for these services." This is factually incorrect. Dr. Rothi's June 30, 2022 RFA makes no mention of six months. It requests home health assistance for "4 hours a day, X 2 days a week PRN". Furthermore Dr. Rothi's accompanying PR- 2 report clearly indicates a follow-up appointment scheduled for August 10, 2022. (See applicant's Exhibit 21, PR-2 reports by Dr. Rothi up through September 20, 2022, pages 8 through 11). On this basis it is clear that the determination of the administrative director was the result of a plainly
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