ADJ15800847 — California WCAB decision

What the panel ordered

Petition for Reconsideration denied, lien claim disallowed for unauthorized treatment services.

Lien claimant Spectrum Medical Group seeks reconsideration of a WCJ's Findings, Award and Orders of January 16, 2024, disallowing part of its lien claim for medical treatment.

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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.

LiensDefendant prevailedback · shoulder

The lien claimant failed to obtain required prior authorization for the physical therapy services provided by Dr. Krause, so the lien reimbursement was denied.

From the decision · page 1For the reasons stated in the portion of the Report quoted below, we will deny the lien claimant's Petition. Before providing reimbursement for medical treatment, "The insurer may require prior authorization of any nonemergency treatment or diagnostic service and may conduct reasonably necessary utilization review pursuant to Section 4610." (Lab. Code, § 4600, subd. (d)(5).) While defendant did generally acknowledge lien claimant as the provider authorized to provide medical treatment to the injured worker, the specific treatment for which lien claimant now seeks reimbursement was never authorized pursuant to Labor Code section 4610 et seq. (Nor

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

Authorized to treat lumbar spine and shoulders; issued initial report and a Request for Authorization for Dr. Krause's treatment which was deferred by defendant.

The WCJ and WCAB noted Dr. Nia had authorization to treat but did not obtain prior authorization for Dr. Krause's physical therapy services, which was required.

From the decision · page 2Applicant selected Dr. Amin Nia to be her primary treating physician on 3/24/22. Lien Claimant's Exhibit 2. On 3/25/22, defendant provided authorization to Dr. Nia to treat Applicant for the lumbar spine and shoulders. Lien claimant's Exhibit 5. Dr. Nia issued an initial report on 3/25/22. Lien claimant's Exhibit 9. This is the only report lien claimant submitted from Dr. Nia as evidence. In reviewing the medical bills submitted by lien claimant, Dr. Nia only performed the initial evaluation. All other dates of service were performed by Dr. Krause. Lien claimant's Exhibit 5. Defendant did not provide authorization for any services performed by Dr. Krause. Dr. Nia did issue a Request for Authorization of treatment for Dr. Krause dated 4/16/22 to which defendant's issued a timely deferral notice. Lien claimant's Exhibit 7 and defendant's Exhibit D, respectively.

otherRelied upon

Performed physical therapy services without authorization from defendant.

No authorization was provided for Dr. Krause's services, and a Request for Authorization was deferred by defendant.

From the decision · page 2Applicant selected Dr. Amin Nia to be her primary treating physician on 3/24/22. Lien Claimant's Exhibit 2. On 3/25/22, defendant provided authorization to Dr. Nia to treat Applicant for the lumbar spine and shoulders. Lien claimant's Exhibit 5. Dr. Nia issued an initial report on 3/25/22. Lien claimant's Exhibit 9. This is the only report lien claimant submitted from Dr. Nia as evidence. In reviewing the medical bills submitted by lien claimant, Dr. Nia only performed the initial evaluation. All other dates of service were performed by Dr. Krause. Lien claimant's Exhibit 5. Defendant did not provide authorization for any services performed by Dr. Krause. Dr. Nia did issue a Request for Authorization of treatment for Dr. Krause dated 4/16/22 to which defendant's issued a timely deferral notice. Lien claimant's Exhibit 7 and defendant's Exhibit D, respectively.

ADJ15800847 · April 8, 2024

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