ADJ11438423 — California WCAB decision

ADJ11438423 · June 20, 2022

Findings and Order of 2021-10-25 rescinded; substituted findings that applicant is entitled to continued inpatient treatment until defendant establishes change in condition and treating physician agrees on care plan; matter returned for further proceedings

Issues decided

Medical opinions weighed

Authorities named

District office

Marina del Rey

What the panel ordered

Petition for reconsideration granted to study factual and legal issues; WCJ Findings and Order of 2021-10-25 reviewed and rescinded; matter returned for further proceedings consistent with new findings

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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.

Medical treatment / UR / IMRApplicant prevailedbrain · head

The Board found that the applicant's RFAs sought continued inpatient treatment previously authorized and thus are not subject to UR without substantial medical evidence of a change in condition; the Board rescinded the WCJ's prior order and substituted findings in favor of the applicant for continued treatment until a change is established and a care plan agreed upon.

From the decision · page 1Applicant and lien claimant Casa Colina seek reconsideration of the Findings and Order (F&O) issued on October 25, 2021, wherein the workers' compensation administrative law judge (WCJ) found as relevant that (1) while employed as a teacher on July 30, 2018, applicant sustained injury arising out of and in the course of employment (AOE/COE) to his brain and head; (2) applicant failed to meet his burden of proving that Patterson v. The Oaks Farms, 79 Cal.Comp.Cases 910, applies to this matter; and (3) applicant's treatment requests must be in the form of requests for authorization (RFAs), which are subject to utilization review (UR) determinations and appealable only through independent medical review (IMR).

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Applicant's February 18, 2021, March 17, 2021, April 22, 2021, and May 14, 2021 RFAs sought continued inpatient treatment previously authorized

Favours Applicant prevailed

This established that the RFAs were not subject to UR absent substantial medical evidence of a change in condition, favoring applicant's entitlement to continued treatment

From the decision · page 16On this record, it is clear that the February 18, 2021, March 17, 2021, April 22, 2021, and May 14, 2021 RFAs sought to continue applicant's ongoing, previously authorized treatment; and, therefore, are not subject to UR in the absence of substantial medical evidence of a change in applicant's circumstances or condition. However, rather than assert that applicant's circumstances and condition have changed, the RFA denials state that applicant's condition has not improved and that he has exceeded the guidelines' length of stay targets as a result.

Denials of RFAs did not account for Dr. Franc's PQME neurology evaluation and re-evaluation reports or Dr. Patterson's May 14, 2021 report indicating risk to applicant and others

Favours Applicant prevailed

Lack of substantial medical evidence of change in condition warranted rescinding prior order and substituting findings for continued treatment

From the decision · page 16Furthermore, the denial of the May 14, 2021 RFA based upon "an imminent and serious threat" to applicant's health was based upon the results of the previous appeal without UR--and the RFAs that followed were also denied without UR, notwithstanding that none of the UR decisions had accounted for Dr. Franc's PQME Neurology Evaluation Report, Dr. Franc's Re- Evaluation Report8, or Dr. Patterson's May 14, 2021 report stating that applicant was "at risk in the home and community as well as other people around him." Thus, the record otherwise lacks substantial medical evidence of a change in applicant's circumstances or condition warranting review or alteration of his treatment. (See Place v. Workmen's Comp. Appeals Bd. (1970) 3 Cal.3d 372 [35 Cal.Comp.Cases 525]; Hegglin v. Workmen's Comp. Appeals Bd. (1971) 4 Cal.3d 162 [36 Cal.Comp.Cases 93] (finding that decisions not based upon adequate medical history or examination are based upon surmise, speculation, conjecture or guess and do not constitute substantial medical evidence).)

Applicant does not have a safe discharge location as family is afraid to accept him due to behavior dyscontrol

Favours Applicant prevailed

Supported entitlement to continued inpatient treatment until care plan agreed upon, favoring applicant

From the decision · page 18The record here reveals that applicant "does not have a safe discharge location as his family is afraid to accept him back in the home due to his behavior dyscontrol." (Ex. 18, David Patterson, M.D. Report Pursuant to CCR 9792.1(C)(4), May 14, 2021.) Hence, applicant is entitled to continued inpatient treatment until a care plan has been agreed upon by his treating physician, Dr. Patterson. Accordingly, we will substitute a finding that applicant is entitled to continued inpatient treatment until his treating physician has agreed upon a care plan appropriate for his medical needs.

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.

PTPRelied upon

Recommended continued inpatient treatment at Casa Colina due to ongoing psychiatric and neuropsychological conditions related to traumatic brain injury; emphasized risk without safe discharge plan.

The Board relied on Dr. Patterson's reports supporting continued inpatient care and risk to applicant and others without safe discharge plan.

From the decision · page 11The patient continues to suffer from depression, anxiety and anger management issues related to his traumatic brain injury. Most recently he had a verbal outburst and aggression where property destruction occurred in the residence due to verbal exchanges between other patients. This is not the first time that this has occurred there the patient's perception is skewed by reality and he misinterprets what is occurring. This places him at risk in the home and community as well as other people around him. Therefore I am recommending that an expedited review of the RFA be performed pursuant to CCR 8792.9.1 (c)(4). Additionally, the patient does not have a safe discharge location as his family is afraid to accept him back in the home due to his behavior dyscontrol. (Ex. 18, David Patterson, M.D. Report Pursuant to CCR 9792.1(C)(4), May 14, 2021.)

QMERelied upon · Neurology

Provided PQME neurology evaluation and re-evaluation reports supporting applicant's ongoing condition and need for treatment.

The Board noted that UR decisions did not account for Dr. Franc's PQME reports, which supported the applicant's condition and treatment needs.

From the decision · page 16On this record, it is clear that the February 18, 2021, March 17, 2021, April 22, 2021, and May 14, 2021 RFAs sought to continue applicant's ongoing, previously authorized treatment; and, therefore, are not subject to UR in the absence of substantial medical evidence of a change in applicant's circumstances or condition. However, rather than assert that applicant's circumstances and condition have changed, the RFA denials state that applicant's condition has not improved and that he has exceeded the guidelines' length of stay targets as a result.

secondary_treaterRelied upon

Diagnosed applicant with major depression, chronic and severe PTSD, and mild traumatic brain injury with concussion; noted high suicide risk and need for inpatient rehabilitation.

The Board incorporated Dr. Ponton's clinical rationale supporting the applicant's psychiatric and neurological condition requiring inpatient care.

From the decision · page 4Clinical Rationale The claimant sustained a traumatic brain injury after a fall. Treatment has included medication, physical therapy, diagnostic studies, and inpatient and outpatient rehabilitation. Per the progress report of 06/04/20 by Dr. Patterson, the claimant's subjective findings included history of traumatic brain injury after falling and hitting his head with loss of consciousness. He was evaluated by Dr. Ponton for having active suicidal ideation, and was diagnosed with major depression, chronic and severe posttraumatic stress disorder, and mild traumatic brain injury with concussion. Dr. Ponton was concerned that he was a high suicidal risk. He was admitted to Casa Colina as he has a known brain injury...

ADJ11438423 · June 20, 2022

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