What the panel ordered
WCAB affirms WCJ Findings and Order dated 2019-09-24 except amended to find lien claimant MH Express did not meet burden of proof for entitlement to payment for certain dates of service; retrospective utilization review ordered only for 5/11/15 date of service; lien claimant to take nothing for other disputed dates
Petition for reconsideration/removal of WCJ Findings and Order granted for further study; WCJ Report and Recommendation to deny reconsideration incorporated; WCJ Findings and Order dated 2019-09-24 reviewed
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.
Lien claimant MH Express failed to prove entitlement to payment for disputed dates of service except for 5/11/15, which must be submitted for retrospective utilization review; defendant's liability for retrospective UR limited accordingly.
From the decision · page 1Defendant seeks reconsideration or in the alternative removal of the Findings and Order (F&O) issued by the workers' compensation administrative law judge (WCJ) on September 24, 2019. By the F&O, the WCJ found in pertinent part that certain dates of service by lien claimant, MH Express, were not properly submitted for utilization review (UR). The WCJ ordered that defendant submit these dates of service for retrospective UR.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Lien claimant MH Express produced only one RFA dated May 8, 2015 for disputed dates of service except 5/11/15 date of service
Favours Defendant prevailed
This failure meant lien claimant did not meet burden of proof for entitlement to payment for those dates, leading to amended order to take nothing for those dates
From the decision · page 3The record contains no other RFAs for medications. There are seven RFAs dating from May 8, 2015 to July 28, 2017 for an ISO brace, interferential unit and supplies for the interferential unit. (Lien Claimant's Exhibit No. 10, RFAs from 5-8-15 to 7-28-17.) These RFAs appear to be
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.
Found applicant's lumbar spine disability was caused in part by January 9, 2015 industrial injury; opined high blood pressure was outside expertise and recommended internal medicine evaluation.
From the decision · page 2Raymond Zarins, M.D. evaluated applicant as the orthopedic panel qualified medical evaluator (QME). He found that applicant's lumbar spine disability was caused in part by his January 9, 2015 claimed industrial injury. (Joint Exhibit Y-2, Report of Dr. Zarins, January 7, 2016, p. 7.) Dr. Zarins opined that applicant's high blood pressure was outside his expertise and that it would be appropriate for him to undergo an internal medicine evaluation for this condition. (Joint Exhibit Y-1, Report of Dr. Zarins, October 7, 2016, p. 2.)
Found applicant's hypertension was aggravated by industrial injury; opined applicant had sleep disorder as result of industrial injury.
From the decision · page 2Paul Grodan, M.D. evaluated applicant as the internal medicine QME. He found that applicant's hypertension was aggravated by his industrial injury. (Joint Exhibit X-1, Report of Dr. Paul Grodan, February 15, 2017, p. 21.) Dr. Grodan also opined that applicant had a sleep disorder as a result of his industrial injury. (Joint Exhibit X-2, Report of Dr. Paul Grodan, September 3, 2017, pp. 2-2.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code sections 3202.5, 5705; Torres v. AJC Sandblasting (2012) 77 Cal.Comp.Cases 1113 (Appeals Board en banc)
Burden of proof rests on party with affirmative of the issue; lien claimant must prove entitlement to payment by preponderance of evidence
Lien claimant MH Express failed to meet burden of proof for disputed dates of service except 5/11/15 date
What proof carried it
The evidence the panel weighed, by kind.
Lien claimant MH Express produced only one RFA dated May 8, 2015 for disputed dates of service except 5/11/15 date of service
From the decision · page 3The record contains no other RFAs for medications. There are seven RFAs dating from May 8, 2015 to July 28, 2017 for an ISO brace, interferential unit and supplies for the interferential unit. (Lien Claimant's Exhibit No. 10, RFAs from 5-8-15 to 7-28-17.) These RFAs appear to be
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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