ADJ12439078 — California WCAB decision

What the panel ordered

WCJ decision affirmed; petition for reconsideration denied

Petition for Reconsideration granted to study factual and legal issues; WCJ Findings of Fact of October 7, 2020 affirmed

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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.

Medical treatment / UR / IMRDefendant prevailedcervical spine · lumbar spine · headaches · thoracic spine · bilateral upper and lower extremities · stomach · teeth · ears

The access standards do not require three physicians in each and every specialty; having three physicians in specialties appropriate to the injured worker's industry satisfies the standard; therefore, the lack of chiropractors as PTPs does not violate access standards.

From the decision · page 3The issue at bar involves Medical Provider Network (MPN) access standards, and the minimum number of physicians of a particular specialty available to act as the primary treating physician (PTP). In an October 7, 2020 Findings of Fact, the undersigned found that so long as the MPN has three physicians of various specialties appropriate to the type of occupation or industry in which the employee is engaged, the access standards set forth in Title 8, Cal. Code Regs. § 9767.5 are satisfied. Applicant is aggrieved by this finding, and seeks removal/reconsideration. The matter is not on calendar.

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

California Labor Code

Labor Code 4616

Requires MPN to have an adequate number and type of physicians to treat common injuries based on occupation or industry.

From the decision · page 5(1) An insurer, employer, or entity that provides physician network services may establish or modify a medical provider network for the provision of medical treatment to injured employees. The network shall include physicians primarily engaged in the treatment of occupational injuries. The administrative director shall encourage the integration of occupational and nonoccupational providers. The number of physicians in the medical provider network shall be sufficient to enable treatment for injuries or conditions to be provided in a timely manner. The provider network shall include an adequate number and type of physicians, as described in Section 3209.3, or other providers, as described in Section 3209.5, to treat common injuries experienced by injured employees based on the type of occupation or industry in which the employee is engaged, and the geographic area where the employees are employed. (Emphasis added.)

Administrative Director Rule

Title 8, California Code of Regulations 9767.5

Requires at least three physicians of each specialty appropriate to the occupation or industry to be available as primary treating physicians, but does not require three of every possible specialty.

From the decision · page 3The issue at bar involves Medical Provider Network (MPN) access standards, and the minimum number of physicians of a particular specialty available to act as the primary treating physician (PTP). In an October 7, 2020 Findings of Fact, the undersigned found that so long as the MPN has three physicians of various specialties appropriate to the type of occupation or industry in which the employee is engaged, the access standards set forth in Title 8, Cal. Code Regs. § 9767.5 are satisfied. Applicant is aggrieved by this finding, and seeks removal/reconsideration. The matter is not on calendar.

ADJ12439078 · May 13, 2021

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

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