ADJ10711761 · December 14, 2022

The WCAB found that defendant improperly terminated medical transportation services without medical evidence of changed condition and without proper utilization review, requiring continuation of services until a proper UR determination is made.

From the decision · page 3On December 9, 2020, the matter proceeded to an expedited hearing. The issues for adjudication were the need for future medical treatment in the form of medical transportation to medical appointments, whether the WCAB has jurisdiction over the transportation dispute in light of the November 5, 2020 UR denial, and whether there was good cause to terminate wheelchair transportation services in October 2020.

Defendant terminated medical transportation services without medical evidence of changed condition or circumstances.

Favours Applicant prevailed

This improper termination violated Labor Code section 4600(a) and Patterson principles, requiring continuation of services.

From the decision · page 4Defendant did not meet its burden to show that the services were no longer reasonably required because of a change in applicant's condition or circumstances. Defendant did not seek an opinion from a physician prior to terminating applicant's medical transportation services. Unilaterally terminating medical treatment that was earlier authorized as reasonably required to cure or relieve the injured worker from the effects of the industrial injury is contrary to section 4600(a) unless supported by substantial medical evidence. (Patterson, supra, 79 Cal.Comp.Cases 910, 917.)

Recommended transportation due to severity of injury.

From the decision · page 2The parties agreed to utilize Dr. Stephen Conrad as the agreed medical examiner. Applicant designated Dr. William Brose as his primary treating physician. Dr. Brose prepared a report dated January 25, 3017, recommending that transportation be provided to applicant due to the severity of his injury. Defendant provided transportation services to applicant to attend his medical appointments. On October 2, 2017, applicant underwent surgical fusion of his spine at L4- L5.

Labor Code section 4600(a)

Labor Code section 4600(a) provides entitlement to medical treatment reasonably required to cure or relieve industrial injury effects, including transportation costs.

Applied to require continuation of medical transportation until proper medical evidence supports termination.

From the decision · page 3DISCUSSION Labor Code section 4600(a)3 provides that an industrially injured worker is entitled, at his/her employer's expense, to medical treatment that is reasonably required to cure or relieve the effects of the industrial injury. (§ 4600(a).) The coverage of section 4600 extends to any medically related services that are reasonably required to cure or relieve the effects of the industrial injury, even if those services are not specifically enumerated in that section. (Smyers v. Workers' Comp. Appeals Bd. (1984) 157 Cal.App.3d 36, 41.) Section 4600 has been construed to include the costs of transportation to obtain treatment and medication, even though such transportation costs are not specifically listed in section 4600. "Medical treatment transportation benefits are an element of overall medical treatment benefits under Labor Code section 4600." (Avalon Bay Foods v. Workers' Comp. Appeals Bd.

Patterson v. The Oaks Farm, 79 Cal.Comp.Cases 910 (2014)

Applied to require defendant to continue medical transportation until a proper utilization review determination is made.

From the decision · page 3(Moore) (1998) 18 Cal.4th 1165, 1173-1175 [63 Cal.Comp.Cases 902, 907-909] (Moore).) In Patterson, supra,79 Cal.Comp.Cases 910, the Appeals Board held that the provision of a nurse case manager is a form of medical treatment under section 4600, that an employer may not unilaterally terminate approved nurse case manager services when there is no evidence of a change in the employee's circumstances or condition showing that the services are no longer reasonably required to cure or relieve the injured worker from the effects of the industrial injury, that the use of an expedited hearing to address the medical treatment issue is authorized by section 5502(b)(1), and that it is not necessary for an injured worker to obtain an RFA to challenge the unilateral termination of the services of a nurse case manager.

Defendant discontinued transportation services without medical reports showing change in condition; UR was done after the fact to justify termination.

From the decision · page 4In this matter, the timeline of events is crucial. The evidence presented indicates that defendant discontinued the transportation unilaterally without medical reports showing a change in applicant's condition, and that UR was done after the fact to justify it. A request for an RFA must be based on a change in applicant's condition or circumstances sufficient to show that the