ADJ12874605 · January 13, 2026

The Appeals Board found that the record was not properly developed on the disputed issues due to changes in applicant's condition and location, requiring further development and reconsideration.

From the decision · page 7III. Although we have preliminarily considered the Petition for Reconsideration, the Answers thereto, and the WCJ's Report, and the record in this matter, we are not persuaded that the record is properly developed on the disputed issues raised in the petition. As contended in defendant's Petition, applicant's location, condition, and even the evidence in this case have been subject to change over the more than one and a half years since Dr. Sangnil recommended the currently disputed items of treatment. Accordingly, taking into account the statutory time constraints for acting on the Petition, and based upon our initial review of the record, we believe reconsideration must be granted to allow sufficient opportunity to further study how the facts of this case apply to unaddressed and developing legal issues, and to ensure that the parties are afforded due process. Thereafter, a final decision after reconsideration will be issued by the Appeals Board, from which any aggrieved person may timely seek a writ of review pursuant to section 5950 et seq.

Applicant is seriously impaired, wheelchair bound, and suffers from functional quadriplegia as noted by physicians and applicant's testimony.

Favours Applicant prevailed

Supports the need for treatment requests including wheelchair access assessment, home modifications evaluation, and wheelchair transportation.

From the decision · page 4the applicant is seriously impaired. She can attempt to ambulate with a walker as she testified. But she suffers from weakness and pain. As stated above, both QME's have noted that she is wheelchair bound. A year ago, she was not able to leave the inpatient care due to her inability to ambulate. The physicians seem to be in agreement that she suffers from "functional quadriplegia."

No evidence of significant improvement in applicant's condition after returning from Alabama.

Favours Applicant prevailed

Undermines defendant's argument that treatment requests are no longer necessary due to improvement.

From the decision · page 4Defendant maintains that since returning from Alabama it seems that there is some improvement in her condition. However, this is not reflected anywhere in the medical reports that were in evidence.

Defendant failed to provide timely utilization review (UR) of Dr. Sangnil's June 21, 2024 Request for Authorization (RFA).

Favours Applicant prevailed

This failure gave the WCJ jurisdiction to determine the medical necessity of the disputed treatment items.

From the decision · page 7In this case, the WCJ, like the WCJ in Omurang, has jurisdiction over the disputed issue of wheelchair transportation, as well as evaluations for possible home modifications including wheelchair access, because of defendant's failure to provide a timely UR in response to Dr. Sangnil's June 21, 2024 RFA. We note that this exercise of jurisdiction under Dubon II does not absolve the WCJ of the duty to apply the provisions of the MTUS, set forth in AD Rules § 9792.20 through 9792.27.23, to each disputed item of treatment.

Record is not properly developed on disputed issues due to changes in applicant's condition and location over time.

Favours neutral

Requires further development and reconsideration to ensure due process and accurate decision-making.

From the decision · page 7III. Although we have preliminarily considered the Petition for Reconsideration, the Answers thereto, and the WCJ's Report, and the record in this matter, we are not persuaded that the record is properly developed on the disputed issues raised in the petition. As contended in defendant's Petition, applicant's location, condition, and even the evidence in this case have been subject to change over the more than one and a half years since Dr. Sangnil recommended the currently disputed items of treatment. Accordingly, taking into account the statutory time constraints for acting on the Petition, and based upon our initial review of the record, we believe reconsideration must be granted to allow sufficient opportunity to further study how the facts of this case apply to unaddressed and developing legal issues, and to ensure that the parties are afforded due process. Thereafter, a final decision after reconsideration will be issued by the Appeals Board, from which any aggrieved person may timely seek a writ of review pursuant to section 5950 et seq.

Requested treatment including wheelchair access assessment, home modifications evaluation, and wheelchair transportation; supported by reports indicating applicant's serious impairment and functional quadriplegia.

Dr. Sangnil's reports and RFAs form the basis for the treatment requests and were considered in the WCJ and Appeals Board analysis.

From the decision · page 2On June 21, 2024, PTP Dr. Sangnil issued a Request for Authorization (RFA) requesting numerous items of treatment, including the three items of treatment that were awarded by the WCJ on October 13, 2025 and presently disputed by defendant: an assessment to make applicant's apartment wheelchair accessible, an evaluation for home modifications, and wheelchair transportation for both treatment and daily activities. The previous Findings and Order dated September 23, 2024 has already determined that there is no timely, compliant utilization review determination or deferral with respect to Dr. Sangnil's June 21, 2024 RFA. Accordingly, the

Requested treatment in April 26, 2024 RFA; WCJ's findings on this treatment were not challenged in the Petition for Reconsideration.

From the decision · page 32 The parties also submitted the issue of whether the treatment requested in treating urologist Dr. Justin Houman's RFA of April 26, 2024 is reasonable and necessary, but the WCJ's findings regarding the treatment requested by Dr. Houman are not specifically challenged by the Petition for Reconsideration.

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Dubon II)

A utilization review (UR) decision is invalid and not subject to independent medical review (IMR) only if it is untimely; legal issues regarding timeliness of UR decisions are resolved by the WCAB, not IMR; if UR decision is untimely, WCAB may determine medical necessity based on substantial medical evidence consistent with Labor Code section 4604.5.

The WCJ had jurisdiction to determine medical necessity due to untimely UR of Dr. Sangnil's June 21, 2024 RFA.

From the decision · page 6prescribed for applicant's pain and psyche. In that opinion, which is often referred to as Dubon II because it modified an earlier en banc opinion in the same case, the appeals board held that:

Applicant's testimony about inability to control urination and defecation, use of walker, and need for assistance with daily activities.

From the decision · page 3On September 25, 2025, the parties once again submitted the yet unresolved issue of whether the treatment requested in Dr. Sangnil's RFA of June 21, 2024 was reasonable and necessary.2 At the September 25, 2025 hearing, the WCJ admitted exhibits into evidence, including Dr. Sangnil's September 19, 2025 report and her RFAs dated June 21, 2024 and September 22, 2025. The WCJ also heard applicant's testimony. Applicant testified that she has been wearing diapers for years, and her daughter has to change her because she cannot do it herself, ever since the date of injury. She cannot control either urination or defecation. She uses a walker. She may be able to take a few steps without it but primarily uses it constantly. She has walked her daughter's little dog and tries to do so in small amounts without the walker, if possible. (Minutes of Hearing and Summary of Evidence dated September 25, 2025, p. 3, lines 6-16.)

Medical reports indicating applicant is wheelchair bound and suffers from functional quadriplegia, with no evidence of significant improvement after returning from Alabama.

From the decision · page 4the applicant is seriously impaired. She can attempt to ambulate with a walker as she testified. But she suffers from weakness and pain. As stated above, both QME's have noted that she is wheelchair bound. A year ago, she was not able to leave the inpatient care due to her inability to ambulate. The physicians seem to be in agreement that she suffers from "functional quadriplegia."