ADJ8192069 · December 24, 2025

A valid, timely UR decision certifying medical necessity is binding on the employer; the WCAB lacks jurisdiction to set aside such a certification except for timeliness issues.

From the decision · page 12Here, the August 5, 2025 UR determination certified the requested home healthcare treatment as medically necessary. Because the UR decision was valid and timely, the determination is binding on the employer and the employer must provide the treatment forthwith to cure or relieve the employee from the effects of the industrial injury. (Lab. Code, § 4600, subd. (a).)

The August 5, 2025 UR determination certified the requested home healthcare as medically necessary and was timely and valid.

Favours Applicant prevailed

A valid, timely UR certification is binding on the employer and precludes WCAB jurisdiction to set it aside except for timeliness issues.

From the decision · page 12Here, the August 5, 2025 UR determination certified the requested home healthcare treatment as medically necessary. Because the UR decision was valid and timely, the determination is binding on the employer and the employer must provide the treatment forthwith to cure or relieve the employee from the effects of the industrial injury. (Lab. Code, § 4600, subd. (a).)

Dr. Smolins opined that applicant required a live-in caregiver due to worsening functional status, inability to perform ADLs, and lack of family support; his opinion was considered in the context of the home healthcare dispute.

PTP's reports and testimony formed the basis for the RFA and UR process; the Board found the UR certification binding and did not reach the merits of medical necessity.

From the decision · page 3claimant is a 37-year-old woman with a complex medical and surgical history including bilateral thoracic outlet syndrome (TOS), complex regional pain syndrome (CRPS) of the left upper extremity, chronic migraine, brachial plexopathy. and progressive functional impairment. She is currently receiving 22 hours per week of home health aide support: however, her condition has worsened, and her functional status no longer supports independent living. The claimant is unable to raise her arms above 90 degrees, has documented atrophy and weakness of both hands, reports frequent dropping of items, including her child, and cannot safely perform essential activities of daily living (ADLs) such as dressing, cooking, and hygiene without assistance. In addition, the claimant suffers from migraine episodes that cause visual disturbances, blackouts, and sensory deficits. further impairing her ability to care for herself and her infant.

Lab. Code § 4610; Dubon v. World Restoration (2014) 79 Cal.Comp.Cases 1298 (en banc); State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230

A valid, timely UR decision certifying medical necessity is binding on the employer; the WCAB lacks jurisdiction to set aside such a certification except for timeliness issues.

The Board applied these authorities to hold that the WCAB could not set aside the August 5, 2025 UR certification of home healthcare, as it was timely and valid.

From the decision · page 12Here, the August 5, 2025 UR determination certified the requested home healthcare treatment as medically necessary. Because the UR decision was valid and timely, the determination is binding on the employer and the employer must provide the treatment forthwith to cure or relieve the employee from the effects of the industrial injury. (Lab. Code, § 4600, subd. (a).)

Subrosa video reviewed by Dr. Smolins, found consistent with applicant's reported limitations.

From the decision · page 5On September 2, 2025, Dr. Smolins issued a report stating in relevant part that he reviewed subrosa video dated March 7, 2025, showing applicant at a gas station, pushing her child in a cart, carrying clothing, carrying a drink, carrying her purse, and carrying her child. (Joint Exhibit 101, Report of Dr. Smolins, September 2, 2024, p. 1.) Dr. Smolins stated that he did not see evidence of pain behavior, but that the videos did not reveal her performing activities that were inconstant with her complaints. (Id. at pp. 1-2.) Dr. Smolins further stated that,

Applicant's testimony regarding her functional limitations and need for assistance with ADLs, as well as Dr. Smolins' reports and review of subrosa video.

From the decision · page 6On September 29, 2025, the issue of applicant's entitlement to home health care services for 24 hours a day for 7 days a week was submitted for disposition. As relevant herein, applicant testified that: She generally sleeps for three to four hours at night. At times, she will choke and stop breathing, and she has started sleepwalking. Once, her family woke up and discovered that the stove was on and that she was in bed with a bowl of cereal. At night, she may "lock up" or go to the restroom. At times, blood rushing to her head may cause her to black out when she goes to the bathroom. She fell and hit her head. She tried wearing diapers but developed sores that became infected. She has difficulty wiping herself and needs assistance scooping her stool out. She does not have regular bowel movements. She is missing teeth, which makes it hard to keep food down. She will throw up and black out. It is also hard to prepare food because she cannot feel heat in her hands. She burned herself while cooking and washing her hands.