What the panel ordered
Petition for Reconsideration denied.
Petition for Reconsideration filed by defendant Cypress Insurance Company challenging Findings and Order of November 26, 2024, denied by WCAB panel decision on March 4, 2025.
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 petition was timely acted upon within 60 days of transmission to the Appeals Board, and the merits of the dental treatment claim were supported by credible, unrebutted medical opinions from Dr. Abdo and Dr. Schames. The defendant's denial based on parts of body defense without medical investigation was rejected.
From the decision · page 1We have considered the allegations of the Petition for Reconsideration and the contents of the report of the workers' compensation administrative law judge (WCJ) with respect thereto. Based on our review of the record, and for the reasons stated in the WCJ's report, which we adopt and incorporate, we will deny reconsideration.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Petition for Reconsideration was timely acted upon within 60 days of transmission to the Appeals Board on January 3, 2025, with decision issued March 4, 2025.
Favours Applicant prevailed
Ensured compliance with Labor Code section 5909 and procedural timeliness of the petition denial.
From the decision · page 2Here, according to Events, the case was transmitted to the Appeals Board on January 3, 2025, and 60 days from the date of transmission is Tuesday, March 4, 2025. This decision is issued by or on Tuesday, March 4, 2025, so that we have timely acted on the petition as required by Labor Code section 5909(a).
Defendant did not serve the deferral notice on applicant and attorney as required by AD Rule 9792.9, failing to meet burden to defer utilization review.
Favours Applicant prevailed
Invalidated defendant's attempt to retroactively defer utilization review, favoring applicant's claim for treatment authorization.
From the decision · page 3Here, the deferral notice by defendant of November 18, 2020 (Exhibit J1) only shows
Credible and unrebutted medical opinions from Dr. Abdo and Dr. Schames supported the need for dental treatment.
Favours Applicant prevailed
Undermined defendant's denial based on parts of body defense without medical investigation, favoring applicant's entitlement to treatment.
From the decision · page 8The problem with this approach is that they left themselves without a defense based on medical opinion. The purpose of UR is to require the doctors to make the decisions on "reasonableness and necessity" under Labor Code § 4600 instead of adjusters, lawyers and judges. By having an adjuster make a decision instead of a doctor, they are now in a position where the only medical opinions in the case, those of Dr. Abdo and Dr. Schames, both support the need for the dental treatment. These opinions are credible expert opinion and un-rebutted.
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.
Credible expert opinion supporting the need for dental treatment including referral to a dentist for loose teeth and pain.
The only medical opinions in the case, both Dr. Abdo and Dr. Schames, support the need for dental treatment and were found credible and unrebutted.
From the decision · page 6The injury was admitted on 03 November 2020 (Exhibit C) and defendant chose Dr. Gary J. Abdo, a doctor of osteopathy, as applicant's treating physician in the Medical Provider Network (MPN) in a letter to that doctor dated 21 October 2020 (See Exhibit E.)
Credible expert opinion supporting the need for dental treatment and authorization for dental treatment.
The only medical opinions in the case, both Dr. Abdo and Dr. Schames, support the need for dental treatment and were found credible and unrebutted.
From the decision · page 6Applicant then sought dental treatment on his own and his attorney served a 4600-letter dated 19 November 2020 appointing Dr. Schames as applicant's primary treating physician. (See Exhibit 6.) Dr. Schames issued an initial report on 25 February 2021 which also requested authorization for dental treatment. (See Exhibits 4 and 5.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 5909
Labor Code section 5909 regarding timely action on petitions for reconsideration.
The Appeals Board acted within 60 days of transmission of the case to the Appeals Board, thus timely denying the petition.
From the decision · page 1Former Labor Code section 5909 provided that a petition for reconsideration was deemed denied unless the Appeals Board acted on the petition within 60 days from the date of filing. (Lab. Code, § 5909.) Effective July 2, 2024, Labor Code section 5909 was amended to state in relevant part that:
Labor Code section 4603.2(b)(1)
Labor Code section 4603.2(b)(1) regarding timely billing by lien claimants.
The lien claimant served billing within 12 months, but on the wrong insurer; statute allows exceptions and no regulations were adopted, so the 12-month limit was moot here.
From the decision · page 6Defendant, CYPRESS INSURANCE COMPANY makes three arguments in their Petition for Reconsideration: First, they argue that the lien claimant failed to timely submit the billing for their services to the employer as required by Labor Code § 4603.2 (b) (1.) This argument is
AD Rule 9792.9
AD Rule 9792.9 regarding deferral of utilization review.
Defendant failed to properly serve deferral notice on applicant and attorney, so deferral of utilization review was not valid.
From the decision · page 3Here, the deferral notice by defendant of November 18, 2020 (Exhibit J1) only shows
What proof carried it
The evidence the panel weighed, by kind.
Defendant did not serve the deferral notice on applicant and his attorney as required by AD Rule 9792.9, thus failing to meet the burden to defer utilization review.
From the decision · page 3Here, the deferral notice by defendant of November 18, 2020 (Exhibit J1) only shows
Credible and unrebutted medical opinions of Dr. Abdo and Dr. Schames supporting dental treatment need.
From the decision · page 8The problem with this approach is that they left themselves without a defense based on medical opinion. The purpose of UR is to require the doctors to make the decisions on "reasonableness and necessity" under Labor Code § 4600 instead of adjusters, lawyers and judges. By having an adjuster make a decision instead of a doctor, they are now in a position where the only medical opinions in the case, those of Dr. Abdo and Dr. Schames, both support the need for the dental treatment. These opinions are credible expert opinion and un-rebutted.
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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.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
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