What the panel ordered
The WCAB granted the Petition for Reconsideration, rescinded the Findings of Fact and Order issued on June 27, 2023, and substituted findings that defendant failed to meet its burden to show a change of circumstances or condition to discontinue home health care services. All other issues were deferred.
Defendant sought reconsideration of the Findings of Fact and Order issued on June 27, 2023, which the WCJ had issued. The WCAB granted reconsideration and rescinded the prior F&O, substituting new findings.
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.
Defendant failed to meet its burden to show a change in applicant's condition or circumstances to justify discontinuing previously authorized home health care services, supported by substantial medical evidence from Drs. Huang and Franc.
From the decision · page 25For the foregoing reasons, IT IS ORDERED that the Petition for Reconsideration of the Findings of Fact and Order issued on June 27, 2023 is GRANTED. IT IS FURTHER ORDERED, as the Decision After Reconsideration, that the Findings of Fact and Order issued on June 27, 2023 is RESCINDED and the following is SUBSTITUTED therefor:
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant failed to establish a change in applicant's condition or circumstances to justify discontinuing home health care services.
Favours Applicant prevailed
This failure meant the defendant could not meet the burden to discontinue previously authorized services, leading to the grant of reconsideration and substitution of findings in applicant's favor.
From the decision · page 25For the foregoing reasons, IT IS ORDERED that the Petition for Reconsideration of the Findings of Fact and Order issued on June 27, 2023 is GRANTED. IT IS FURTHER ORDERED, as the Decision After Reconsideration, that the Findings of Fact and Order issued on June 27, 2023 is RESCINDED and the following is SUBSTITUTED therefor:
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.
Dr. Huang testified there was no change in applicant's condition that would warrant termination of home health care services. He issued RFAs supporting continued care.
Dr. Huang is the primary treating physician and in the best position to opine on medical necessity; his testimony and reports were credited as substantial evidence.
From the decision · page 1Defendant seeks reconsideration of the Findings of Fact and Order (F&O) issued on June 27, 2023, wherein the workers' compensation administrative law judge (WCJ) found, in pertinent part, that (1) while employed by defendant as a Ready-Mix concrete driver on May 25, 2018, applicant sustained injury arising out of and in the course of employment to the head and brain, and that the issues as to claimed body parts are deferred; (2) applicant's condition is found to be `catastrophic'; (3) Labor Code Section 4610(i)(3)1 is applicable to this case because applicant faced an imminent and serious threat due to his medical condition; (4) none of defendant's Utilization Reviews (UR) were conducted within seventy-two hours; (5) Independent Medical Review (IMR) does not apply to an untimely UR or a Patterson fact pattern; (6) pursuant to Patterson, if an employer authorizes medical services, the applicant does not have the burden of proving the ongoing reasonableness and necessity of the services; (7) defendant failed to meet the burden of showing that the continued provision of services is no longer reasonably required due to a change of applicant's circumstances or condition; (8) the medical reports of Drs. Huang and Franc, and Dr. Huang's testimony, constitute substantial medical evidence; and (9) all other issues are moot.
Dr. Franc supported the medical necessity of continued home health care services.
Dr. Franc's medical reports were considered substantial medical evidence supporting continued care.
From the decision · page 1Defendant seeks reconsideration of the Findings of Fact and Order (F&O) issued on June 27, 2023, wherein the workers' compensation administrative law judge (WCJ) found, in pertinent part, that (1) while employed by defendant as a Ready-Mix concrete driver on May 25, 2018, applicant sustained injury arising out of and in the course of employment to the head and brain, and that the issues as to claimed body parts are deferred; (2) applicant's condition is found to be `catastrophic'; (3) Labor Code Section 4610(i)(3)1 is applicable to this case because applicant faced an imminent and serious threat due to his medical condition; (4) none of defendant's Utilization Reviews (UR) were conducted within seventy-two hours; (5) Independent Medical Review (IMR) does not apply to an untimely UR or a Patterson fact pattern; (6) pursuant to Patterson, if an employer authorizes medical services, the applicant does not have the burden of proving the ongoing reasonableness and necessity of the services; (7) defendant failed to meet the burden of showing that the continued provision of services is no longer reasonably required due to a change of applicant's circumstances or condition; (8) the medical reports of Drs. Huang and Franc, and Dr. Huang's testimony, constitute substantial medical evidence; and (9) all other issues are moot.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Patterson
An employer may not unilaterally cease to provide approved medical treatment 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.
Applied to deny defendant's attempt to discontinue home health care services without showing change in condition.
From the decision · page 16In Patterson, the Board held in pertinent part that: An employer may not unilaterally cease to provide 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... [And] It is not necessary for an injured worker to obtain a Request for Authorization to challenge the unilateral termination of the services of a nurse case manager. (79 Cal. Comp. Cases at p. 917.) We concluded that: 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. (Emphasis added.)
What proof carried it
The evidence the panel weighed, by kind.
Credible testimony from Dr. Huang that there was no change in applicant's circumstances or condition to warrant discontinuation of care.
From the decision · page 19It is found that the defendant acknowledged the reasonableness and necessity of the medical treatment at issue when it first authorized it. The board relied on the credible testimony from Dr. Huang that there was no change in the applicant's circumstance and no reasonable basis to discharge him from care. National Cement Co., Inc. v. WCAB (Rivota) (2021) 86 CCC 595 (writ denied). See also Castillo v. Midnight Impressions (2022) 87 CCC
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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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