ADJ17821210 · August 29, 2025

The Appeals Board panel found that the petition for reconsideration was timely and properly noticed, and the WCJ's report was adopted and incorporated, leading to denial of the petition.

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, and for the additional reasons given below, we will deny reconsideration.

The WCJ and Appeals Board found that defendants failed to show a material change in circumstances to justify a new utilization review for ongoing brain injury rehabilitation care, thus the prior authorization remains valid and the treatment must continue.

From the decision · page 7An expedited hearing was held before WCJ Hursh on 3/19/2025. The WCJ determined that the medical evidence set forth in the peer review reports failed to demonstrate any significant change in condition. The rehabilitation program was ongoing treatment having been instigated since January, 2024. Hence the WCJ invoked the rule of Patterson v. The Oaks Farm (2014) 79 CCC 910. He invalidated the UR Determination indicating that the Petitioner could not unilaterally discontinue previously authorized ongoing care without a showing of a significant change of condition. He invoked the Appeals Board's jurisdiction to find that the treatment requested was reasonably necessary to cure or relieve the Applicant of the effects of the injury and ordered the Defendant to provide same.

Applicant sustained a significant brain injury at work on 11/21/2022 requiring brain surgery.

Favours Applicant prevailed

This injury and ongoing symptoms justify the need for continued outpatient brain rehabilitation care.

From the decision · page 6As stated above, this Applicant sustained a brain injury on 11/21/2022 when his head struck a metal pole resulting in subdural hematomas requiring brain surgery. He has remained under the care of the primary treating physician, Vibhay Prasad M.D. at the Centre for Neuro Skills.

Defendants failed to show a material change in applicant's medical condition since prior authorization of ongoing rehabilitation care on July 22, 2024.

Favours Applicant prevailed

Without evidence of change, defendants cannot justify a new utilization review or termination of care.

From the decision · page 4... [T]he whole point of Patterson is that a Form RFA is not required in certain circumstances involving care of an ongoing nature. The decision is about when an RFA is required, and if one is not required in the first place, then there can be no valid [utilization review] therefrom, timely or otherwise.... Defendant's argument that its allegedly timely and valid [utilization review] determination provides substantial medical evidence of a change in circumstances is inapplicable because the [utilization review] should never have been issued in the first place under the reasoning in Patterson, as explained above. (Burton, supra, 89 Cal. Comp. Cases 977, at 980.) As explained in the WCJ's Report, the defendants in the present case have not met their burden of proof to show that there has been a change of circumstances since home care was found to be reasonable and necessary on July 22, 2024. None of the exhibits admitted at expedited hearing on March 19, 2025 provide substantial medical evidence of a significant change in applicant's medical condition.

Dr. Prasad documented ongoing symptoms and the need for continued outpatient brain rehabilitation care, opposing the defendants' attempts to discontinue treatment without evidence of a material change in condition.

Dr. Prasad's reports and appeal supported the continuation of treatment and showed no significant change in condition to justify termination.

From the decision · page 6As stated above, this Applicant sustained a brain injury on 11/21/2022 when his head struck a metal pole resulting in subdural hematomas requiring brain surgery. He has remained under the care of the primary treating physician, Vibhay Prasad M.D. at the Centre for Neuro Skills.

Labor Code section 5909

A petition for reconsideration must be acted upon within 60 days of transmission of the case to the Appeals Board, with notice to parties.

Applied to determine timeliness and notice of petition for reconsideration.

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:

Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910

Utilization review determinations for ongoing treatment cannot be unilaterally discontinued by defendants without showing a material change in applicant's condition.

Applied to find that defendants failed to meet burden to show change in circumstances to justify new utilization review.

From the decision · page 2In addition to the reasons set forth in the WCJ's Report, we note that in Allied Signal Aero. v. Workers' Comp. Appeals Bd. (Wiggs) (2019) 35 Cal.App.5th 1077 [86 Cal.Comp.Cases 367], the issue was both an increase in the level of care and whether defendant agreed to waive utilization review or refer it to a nurse for alternative dispute resolution on a one-time basis. In contrast, the issue in the present case is whether ongoing brain injury rehabilitation care at the Centre for Neuro Skills, which had already been certified as reasonable and necessary through the utilization review process on July 22, 2024 and provided by defendants, should have been sent for a redundant subsequent utilization review absent any evidence that material facts had changed. The WCJ correctly applied the reasoning in Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910 (Appeals Board Significant Panel Decision), and National Cement Co. v. Workers' Comp. Appeals Bd. (Rivota) (2021) 86 Cal.Comp.Cases 595 (writ denied), both of which are cited in the Report, to find that defendants had not met their burden to show a change of circumstances in order to

Medical evidence failed to demonstrate any significant change in applicant's condition to justify termination of ongoing rehabilitation care.

From the decision · page 7An expedited hearing was held before WCJ Hursh on 3/19/2025. The WCJ determined that the medical evidence set forth in the peer review reports failed to demonstrate any significant change in condition. The rehabilitation program was ongoing treatment having been instigated since January, 2024. Hence the WCJ invoked the rule of Patterson v. The Oaks Farm (2014) 79 CCC 910. He invalidated the UR Determination indicating that the Petitioner could not unilaterally discontinue previously authorized ongoing care without a showing of a significant change of condition. He invoked the Appeals Board's jurisdiction to find that the treatment requested was reasonably necessary to cure or relieve the Applicant of the effects of the injury and ordered the Defendant to provide same.