ADJ882004 — California WCAB decision

What the panel ordered

Petition for reconsideration granted; WCJ's determination that OMFS applies affirmed; issue of actual payment deferred to trial level for informal adjustment.

Petition for reconsideration of the December 8, 2025 Findings and Order granted by the WCAB panel, with partial affirmance and partial amendment.

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This docket was decided more than once. Shown here is the latest released decision; we also hold April 25, 2023.

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.

LiensMixed

The WCAB affirmed the WCJ's determination that the OMFS applies to the lien claimants' charges because the lien claimants failed to prove extraordinary circumstances justifying fees above OMFS, but deferred the issue of actual payment to lien claimants for further informal adjustment at trial level.

From the decision · page 9In summary, to the extent that lien claimants' usual and customary charges might be permissible under AD Rule 9792(c), we concur with the WCJ's determination that the record does not support the "extraordinary circumstances related to the unusual nature of the services rendered" necessary to justify fees in excess of the OMFS. Accordingly, we will affirm the WCJ's determination that the OMFS is applicable to lien claimants' charges herein. However, insofar as lien claimants' Petition raises a colorable dispute as to actual receipt of the OMFS reimbursement of its liens, an issue not submitted for decision from trial, we will rescind the WCJ's Findings of Fact that "defendant has paid the liens per the OMFS" and defer the issue. Upon return of this matter to the trial level, the parties may informally adjust issues attendant to the payment and receipt of the reimbursement at OMFS rates, with jurisdiction reserved to the WCJ in the event of further dispute.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Lien claimants did not prove extraordinary circumstances related to unusual nature of services rendered.

Favours Defendant prevailed

This failure meant fees above OMFS were not justified, affirming OMFS applicability.

From the decision · page 8Following our complete review of the record occasioned by lien claimants' petition, we agree with the WCJ's conclusion that lien claimants have not met their affirmative burden of establishing the existence of "extraordinary circumstances related to the unusual nature of the services rendered," justifying the award of fees exceeding OMFS. (Cal. Code Regs, tit. 8, § 9792, subd. (c).) We therefore concur with the WCJ's determination that the OMFS is applicable to the charges for services asserted by lien claimants.

No evidence of claim denial or compensability dispute at time of services; delay in payment not equivalent to denial.

Favours Defendant prevailed

This undermined lien claimants' argument for usual and customary charges above OMFS.

From the decision · page 8Lien claimants assert that the defendant's 12-year delay in payment of lien claimants' billing "demonstrates that both doctors treated on what was effectively a denied claim." (Petition, at p. 11:11.) However, we are not persuaded that a delay in payment to a medical provider is tantamount to a denial of compensability in the first instance. The submitted evidence does not reflect a claim denial notice, nor did lien claimants interpose witness testimony supporting a compensability dispute at the time the services were rendered. Nor does the record demonstrate how even a considerable delay in payment establishes the existence of the "extraordinary circumstances" related to the provision of "unusual services" as set forth in AD Rule 9792. We further agree with the WCJ that the educational background and professional accomplishments of lien claimants herein, although laudable, do not otherwise establish the existence of the type of extraordinary circumstances that would justify a departure from the OMFS. (Petition, at p. 17:25; Report, at p. 7.) And although the parties have stipulated that services provided by lien claimants were medically necessary, the evidentiary record does not reflect that the services were unusual services necessitated by or related to extraordinary circumstances.

What proof carried it

The evidence the panel weighed, by kind.

Medical recordsfavours Defendant prevailed

Lien claimants failed to prove extraordinary circumstances related to unusual nature of services to justify fees above OMFS.

From the decision · page 8Following our complete review of the record occasioned by lien claimants' petition, we agree with the WCJ's conclusion that lien claimants have not met their affirmative burden of establishing the existence of "extraordinary circumstances related to the unusual nature of the services rendered," justifying the award of fees exceeding OMFS. (Cal. Code Regs, tit. 8, § 9792, subd. (c).) We therefore concur with the WCJ's determination that the OMFS is applicable to the charges for services asserted by lien claimants.

Medical recordsfavours Defendant prevailed

No evidence of claim denial notice or compensability dispute at time of services rendered; delay in payment not equivalent to denial.

From the decision · page 8Lien claimants assert that the defendant's 12-year delay in payment of lien claimants' billing "demonstrates that both doctors treated on what was effectively a denied claim." (Petition, at p. 11:11.) However, we are not persuaded that a delay in payment to a medical provider is tantamount to a denial of compensability in the first instance. The submitted evidence does not reflect a claim denial notice, nor did lien claimants interpose witness testimony supporting a compensability dispute at the time the services were rendered. Nor does the record demonstrate how even a considerable delay in payment establishes the existence of the "extraordinary circumstances" related to the provision of "unusual services" as set forth in AD Rule 9792. We further agree with the WCJ that the educational background and professional accomplishments of lien claimants herein, although laudable, do not otherwise establish the existence of the type of extraordinary circumstances that would justify a departure from the OMFS. (Petition, at p. 17:25; Report, at p. 7.) And although the parties have stipulated that services provided by lien claimants were medically necessary, the evidentiary record does not reflect that the services were unusual services necessitated by or related to extraordinary circumstances.

ADJ882004 · February 2, 2026

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

The rules the panel named

What proof carried it

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