ADJ19406087 · February 3, 2026

The WCJ found the treatment request reasonable and necessary and that defendant failed to show a change in condition or meet statutory requirements for denial. The WCAB granted reconsideration to further review the merits and statutory law.

From the decision · page 1The WCJ found, in pertinent part, that applicant, while employed on May 23, 2024 as a driver, at Irvine, California, sustained injury arising out of in the course of employment (AOE/COE) to his left eye, left side of face, head, neck, left arm, chest, left shoulder, and injury in the form of a concussion with all other body parts deferred. The WCJ further found that the treatment request for continual care at Casa Colina is reasonable and necessary, and that defendant has not provided evidence of a change in applicant's condition or circumstances that show that applicant's treatment at Casa Colina is no longer reasonably required. Additionally, the WCJ found that applicant does not have the burden of being required to provide a new Request for Authorization (RFA), and that defendant failed to meet the requirements of Labor Code Section 4610(i)(4)(C)1 and Title 8, California Code of Regulations 9792.9.1(e)(6). Applicant was awarded further medical treatment at Casa Colina.

Applicant sustained injury arising out of and in the course of employment on May 23, 2024 to multiple body parts including left eye, face, head, neck, left arm, chest, left shoulder, and concussion.

Favours Applicant prevailed

Establishes compensable injury and basis for medical treatment entitlement.

From the decision · page 1The WCJ found, in pertinent part, that applicant, while employed on May 23, 2024 as a driver, at Irvine, California, sustained injury arising out of in the course of employment (AOE/COE) to his left eye, left side of face, head, neck, left arm, chest, left shoulder, and injury in the form of a concussion with all other body parts deferred. The WCJ further found that the treatment request for continual care at Casa Colina is reasonable and necessary, and that defendant has not provided evidence of a change in applicant's condition or circumstances that show that applicant's treatment at Casa Colina is no longer reasonably required. Additionally, the WCJ found that applicant does not have the burden of being required to provide a new Request for Authorization (RFA), and that defendant failed to meet the requirements of Labor Code Section 4610(i)(4)(C)1 and Title 8, California Code of Regulations 9792.9.1(e)(6). Applicant was awarded further medical treatment at Casa Colina.

Defendant failed to provide evidence of a change in applicant's condition or circumstances to justify denial of continued treatment at Casa Colina.

Favours Applicant prevailed

Supports WCJ's finding that treatment request is reasonable and necessary.

From the decision · page 5On October 31, 2025, the WCJ issued an F&A in which it was found in pertinent part that; (1) on May 23, 2024, applicant sustained injury AOE/COE to his left eye, left side of face, head, neck, left arm, chest, left shoulder, and concussion; (2) exhibits A, K, L,M,N,Q, and R, are admitted into evidence; (3) the treatment request for continual care at Casa Colina is reasonable and necessary; (4) defendant has not provided evidence of a change in applicant's condition or circumstances that show that applicant's treatment at Casa Colina is no longer reasonably required; (5) applicant does not have the burden of being required to provide a new RFA, thereby starting the process over again; (6) defendant failed to meet the requirements of Labor Code Section 4610(i)(4)(C) and Title 8, California Code of Regulations 9792.9.1(e)(6); and (7) applicant is entitled to further medical treatment at Casa Colina, which was awarded by the WCJ. (F&A, 10/31/25, pp. 1-2.)

Defendant's retroactive non-certification of previously certified June 19, 2025 RFA may conflict with Labor Code section 4610.3(a).

Favours Applicant prevailed

Raises legal issue affecting validity of denial and treatment authorization.

From the decision · page 6Based upon our initial review, it appears that the retroactive non-certification on August 14, 2025 of the previously certified/authorized June 19, 2025 RFA may be in conflict with section 4610.3(a). Further, the existing record is unclear as to whether applicant was treating as an inpatient at Casa Colina during the eight-month gap between October 2024 and June 2025 and whether in-patient treatment at Casa Colina following the June 19, 2025 RFA/UR certification was provided and started.

Submitted RFAs for continued care at Casa Colina Transitional Living Center due to uncontrolled pain, status post clavicle surgery, and traumatic brain injury.

From the decision · page 4On June 19, 2025, Dr. David Patterson of Casa Colina submitted an RFA for continued care at the Casa Colina Transitional Living Center Interdisciplinary Post-Acute Residential Rehabilitation Program, with 4§ 6 hours of therapy, due to uncontrolled pain, status post clavicle surgery, and traumatic brain injury. The RFA is signed and dated June 19, 2025 and the FAX sheet is dated Friday, June 20, 2025 3:53 p.m. (Ex. 8.)

Labor Code Section 4600

Section 4600 requires employer to provide reasonable medical treatment to cure or relieve effects of industrial injury.

Applied to determine employer's obligation for medical treatment.

From the decision · page 5We highlight several legal principles that may be relevant to our review of this matter. Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of the industrial injury. (Lab. Code, § 4600(a).) An employer's review of an employees' medical treatment requests are governed solely by UR. (Lab. Code, § 4610(g); State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236 [73 Cal.Comp.Cases 981].) Section 4610 provides time limits within which a UR decision must be made by the employer. (Lab. Code, § 4610.) These time limits are mandatory.

Labor Code Section 4610

Employer's review of medical treatment requests governed solely by Utilization Review (UR) with mandatory time limits.

Applied to assess timeliness and jurisdiction over UR decisions.

From the decision · page 5We highlight several legal principles that may be relevant to our review of this matter. Section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of the industrial injury. (Lab. Code, § 4600(a).) An employer's review of an employees' medical treatment requests are governed solely by UR. (Lab. Code, § 4610(g); State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 236 [73 Cal.Comp.Cases 981].) Section 4610 provides time limits within which a UR decision must be made by the employer. (Lab. Code, § 4610.) These time limits are mandatory.

Dubon II (2014) 79 Cal.Comp.Cases 1298

If UR decision is untimely, Appeals Board may determine medical necessity; if timely, disputes resolved by IMR.

Applied to determine jurisdiction over medical necessity disputes.

From the decision · page 5In Dubon v. World Restoration, Inc. (Dubon II) (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc), the Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Dubon II, supra, pages 1299, 1300.)

Labor Code Section 4610(i)(4)(C)

Notice of denial to employee's physician and agreed care plan required before discontinuing medical care.

Applied to assess defendant's compliance with denial procedures.

From the decision · page 6Section 4610(i)(4)(C) sets forth the requirement for notice of denial to the employee's physician and the creation of an agreed upon care plan with the employee physician.

Labor Code Section 4610.3(a)

Employer may not rescind or modify authorization after treatment has been provided except for treatments not yet provided.

Applied to evaluate retroactive non-certification of treatment.

From the decision · page 6Section 4610.3(a) sets forth guidelines following authorized medical treatment disallowing the employer an opportunity to rescind the authorization after treatment has been provided.

Defendant failed to provide evidence of a change in applicant's condition or circumstances to justify denial of treatment.

From the decision · page 5On October 31, 2025, the WCJ issued an F&A in which it was found in pertinent part that; (1) on May 23, 2024, applicant sustained injury AOE/COE to his left eye, left side of face, head, neck, left arm, chest, left shoulder, and concussion; (2) exhibits A, K, L,M,N,Q, and R, are admitted into evidence; (3) the treatment request for continual care at Casa Colina is reasonable and necessary; (4) defendant has not provided evidence of a change in applicant's condition or circumstances that show that applicant's treatment at Casa Colina is no longer reasonably required; (5) applicant does not have the burden of being required to provide a new RFA, thereby starting the process over again; (6) defendant failed to meet the requirements of Labor Code Section 4610(i)(4)(C) and Title 8, California Code of Regulations 9792.9.1(e)(6); and (7) applicant is entitled to further medical treatment at Casa Colina, which was awarded by the WCJ. (F&A, 10/31/25, pp. 1-2.)

Defendant's retroactive non-certification of previously certified RFA may conflict with Labor Code section 4610.3(a).

From the decision · page 6Based upon our initial review, it appears that the retroactive non-certification on August 14, 2025 of the previously certified/authorized June 19, 2025 RFA may be in conflict with section 4610.3(a). Further, the existing record is unclear as to whether applicant was treating as an inpatient at Casa Colina during the eight-month gap between October 2024 and June 2025 and whether in-patient treatment at Casa Colina following the June 19, 2025 RFA/UR certification was provided and started.