Compliance by AMEs and QMEs with Administrative Director Evaluation and Reporting Guidelines. 8 CCR § 35.5

What panels did with this rule

Released decisions that named § 35.5, with the passage each turned on. A panel decision persuades; it does not bind.

• ADJ11422165 · 2026-02-24 · Sacramento District Office8 CCR § 35.5

  Determinative passage · p.4Thus, while any future request for medical treatment pursuant to section 4600(a) would be subject to evaluation for medical necessity through the utilization review process, the underlying determination of entitlement to seek that future medical treatment must contemplate whether the need for treatment may arise over the course of the injured worker's lifetime. We further observe that per Administrative Director Rule 35.5, subd. (g)(2), the QME "shall not provide an opinion on any disputed medical treatment issue, but shall provide an opinion about whether the injured worker will need future medical care to cure or relieve the effects of an industrial injury." (Cal. Code Regs., tit. 8, § 35.5(g)(2).)

  Guided QME's opinion on future medical treatment entitlement.

  Official decision · page 4 →
• ADJ11238147 · 2025-10-13 · Sacramento District Office8 CCR § 35.5

  Determinative passage · p.3(C) Has not less than five years' postdoctoral experience in the diagnosis and treatment of emotional and mental disorders, and has served as an agreed medical evaluator on eight or more occasions prior to January 1, 1990. (Lab. Code § 139.2(b)(5)(A)-(C).) Further, the QME "shall address all contested medical issues arising from all injuries reported on one or more claim forms prior to the date of the employee's appointment with the medical evaluator that are issues within the evaluator's scope of practice and areas of clinical competence." (Cal. Code Regs., tit. 8, § 35.5(c)(1).) The QME has an obligation to advise the parties in writing if any of the disputed medical issues are outside of the QME's scope of practice and area of clinical competency so that the parties can request an additional evaluation in another specialty. (Cal. Code Regs., tit.

  Dr. Shirikian addressed all contested psychiatric issues within her scope as QME in psychology.

  Official decision · page 3 →
• ADJ10746901 · 2024-04-11 · San Diego District Office8 CCR § 35.5

  Determinative passage · p.4Next, regarding the issue of whether QME Dr. Roland should review and consider the report from Dr. Smith, DIR rule 35.5 states:

  QME Dr. Roland cannot address disputed medical treatment issues such as the need for left hip surgery.

  Official decision · page 4 →
• ADJ11969576 · 2023-09-12 · Van Nuys District Office8 CCR § 35.5

  Determinative passage · p.6Here, the parties dispute the need for an additional QME panel in internal medicine so there is no joint agreement on the need for an additional evaluator in a different specialty. However, we conclude that good cause exists for a QME in internal medicine. Applicant claimed industrial injury to her arm, back, circulatory system, worsening of hypertension, and blood infection. (FA&O, Findings of Fact 1 & 2.) PTP Dr. Mahboubian recommended a specialty referral for an internal medicine evaluation and treatment. (Ex. 2, pp. 1-3; Ex. 3, pp. 1-2.) Although AME Dr. Newton was aware of applicant's other claimed injuries (Ex. X1, p. 3, 7-8; Ex. X3, pp. 3-5; Ex. X4, pp. 22-23), he failed to address these contested medical issues or advise the parties of any disputed medical issues outside of his scope of practice and area of clinical competency as required. (Cal. Code Regs., tit. 8, § 35.5(c)(1), (d); Gill (Amarjeet) v. County of Fresno (2021) 86 Cal.Comp.Cases 609, 621 ["In the event that there are disputed medical issues in either claim that [QME] Dr. Lin is unable to address, it is incumbent on the QME to address those issues he is able to address and to advise the parties of any disputed medical issues outside of his scope of practice and area of clinical competency."].)

  The Appeals Board applied these rules to find good cause for an additional QME panel in internal medicine due to the orthopedic AME's failure to address all disputed medical issues.

  Official decision · page 6 →
• ADJ11231953 · 2023-06-05 · Fresno District Office8 CCR § 35.5

  Determinative passage · p.4As Cost Petitioner correctly points out, the California Code of Regulations clearly sets forth the duties of medical/legal evaluators:

  Applied to require the QME to address causation issues raised by applicant's counsel despite defendants' cover letter restricting causation discussion.

  Official decision · page 4 →
• ADJ10586674 · 2022-08-30 · San Francisco District Office8 CCR § 35.5

  Determinative passage · p.2At the evaluator's earliest opportunity and no later than the date the report is served, the evaluator shall advise the parties in writing of any disputed medical issues outside of the evaluator's scope of practice and area of clinical competency in order that the parties may initiate the process for obtaining an additional evaluation pursuant to section 4062.1 or 4062.2 of the Labor Code and these regulations in another specialty. In the case of an Agreed Panel QME or a panel QME, the evaluator shall send a copy of the written notification provided to the parties to the Medical Director at the same time. However, only a party's request for an additional panel, with the evaluator's written notice under this section attached, or an order by a Workers' Compensation Administrative Law Judge, will be acted upon by the Medical Director to issue a new QME panel in another specialty in the claim.

  Evaluator must notify parties of disputed medical issues outside evaluator's scope to initiate additional evaluation process; only party request with evaluator's notice or WCJ order triggers Medical Director to issue new QME panel.

  Official decision · page 2 →
• ADJ9341102 · 2021-05-18 · Van Nuys District Office8 CCR § 35.5

  Determinative passage · p.6Defendant's petition argues that the need for attendant care for cognitive and memory problems as identified by Dr. Patterson is rebutted by surveillance videos that show applicant driving, jogging, and running errands. The undersigned disagrees. The depiction of isolated incidents of travel, bodily movement, and going to stores is not enough by itself to disprove a diagnosis of unreliable cognitive function from a medical expert. If the video had been reviewed by Dr. Patterson and caused him to change his mind about treatment recommendations, the result would of course have been different. Instead, defendants rely on the medical expert opinions of the QMEs in this case as rebuttal of the treatment recommendations of treating physician Dr. Patterson. This reliance on QME opinion regarding treatment disputes is contrary to California Code of Regulations, title 8, section 35.5(g)(2), which dictates that "[f]or any evaluation

  The petition's reliance on QME opinions to rebut treatment recommendations was rejected as contrary to this regulation.

  Official decision · page 6 →