ADJ12704660 — California WCAB decision

ADJ12704660 · June 13, 2022

Petition for reconsideration granted; Findings and Order on Appeal of Administrative Director's IMR Determination rescinded; dispute remanded to Administrative Director for submission to a different independent review organization or reviewer.

Issues decided

Medical opinions weighed

Authorities named

District office

Riverside

What the panel ordered

Applicant sought reconsideration of the Findings and Order on Appeal of Administrative Director's IMR Determination issued on March 22, 2022, challenging the denial of home healthcare services.

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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 / IMRApplicant prevailedhome healthcare services

The IMR determination applied the MTUS guidelines in a plainly erroneous manner based on ordinary knowledge and not expert opinion, failing to properly consider applicant's severe difficulty with activities of daily living and use of assistive device as homebound.

From the decision · page 10For the foregoing reasons, IT IS ORDERED that the Petition for Reconsideration of the Findings and Order on Appeal of Administrative Director's IMR Determination issued on March 22, 2022 is GRANTED. IT IS FURTHER ORDERED, as the Decision After Reconsideration of the Workers' Compensation Appeals Board, that the Findings and Order on Appeal of Administrative Director's IMR Determination issued on March 22, 2022 is RESCINDED, and the following is SUBSTITUTED therefor: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.

Applicant has severe difficulty with activities of daily living and ambulates with an assistive device such as a walker.

Favours Applicant prevailed

This fact supports the finding that the applicant is homebound and requires home healthcare, contrary to the IMR determination.

From the decision · page 7Here, the IMR reviewer relied upon MTUS providing that "[h]ome healthcare is selectively recommended... to overcome deficits in activities of daily living... [and indicated when] the patient is unable to leave the home without... [a] walker." (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, pp. 14-15; Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) In doing so, the reviewer explicitly recognized medical evidence that applicant has "' severe difficulty' with activities of daily living" and "ambulates with [an] assistive device" due to those difficulties. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) Yet the reviewer concluded that home healthcare was "not medically necessary" without explaining how this evidence fell outside the MTUS or citing evidence that applicant was able to perform daily living activities without difficulty or ambulate without an assistive device or was not "homebound" as her primary treating physician had opined. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 8; Ex. 1, Dr. Ahmed's June 14, 2021 Report, pp. 2-11.)

The IMR determination improperly relied on lack of documentation of home health evaluation to deny home healthcare.

Favours Applicant prevailed

The Board found this reliance was a plainly erroneous application of MTUS guidelines and supported granting reconsideration.

From the decision · page 7In addition, the IMR reviewer relied upon MTUS providing that a "home evaluation is necessary to develop the home health care treatment plan" as a separate ground supporting the conclusion that home healthcare was not medically necessary. (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15; Ex. 4, IMR Final Determination dated January 12, 2022, p. 8.) However, the MTUS do not state that a home evaluation must be performed in order for home healthcare to be recommended, but rather to ensure that such care is provided safely and correctly. (Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15.) It follows that the IMR reviewer's conclusion that the lack of "documentation of home health evaluation" provided an additional ground to deny applicant's home healthcare request was also based upon a plainly erroneous application of the MTUS.

What proof carried it

The evidence the panel weighed, by kind.

Medical recordsfavours Applicant prevailed

Lack of documentation of home health evaluation was improperly used to deny home healthcare request.

From the decision · page 7In addition, the IMR reviewer relied upon MTUS providing that a "home evaluation is necessary to develop the home health care treatment plan" as a separate ground supporting the conclusion that home healthcare was not medically necessary. (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15; Ex. 4, IMR Final Determination dated January 12, 2022, p. 8.) However, the MTUS do not state that a home evaluation must be performed in order for home healthcare to be recommended, but rather to ensure that such care is provided safely and correctly. (Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, p. 15.) It follows that the IMR reviewer's conclusion that the lack of "documentation of home health evaluation" provided an additional ground to deny applicant's home healthcare request was also based upon a plainly erroneous application of the MTUS.

activities of daily livingfavours Applicant prevailed

Applicant's severe difficulty with activities of daily living and use of assistive device such as a walker.

From the decision · page 7Here, the IMR reviewer relied upon MTUS providing that "[h]ome healthcare is selectively recommended... to overcome deficits in activities of daily living... [and indicated when] the patient is unable to leave the home without... [a] walker." (Report, p. 2; Ex. A, Initial Approach to Treatment Guidelines, June 30, 2017, pp. 14-15; Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) In doing so, the reviewer explicitly recognized medical evidence that applicant has "' severe difficulty' with activities of daily living" and "ambulates with [an] assistive device" due to those difficulties. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 6-8.) Yet the reviewer concluded that home healthcare was "not medically necessary" without explaining how this evidence fell outside the MTUS or citing evidence that applicant was able to perform daily living activities without difficulty or ambulate without an assistive device or was not "homebound" as her primary treating physician had opined. (Ex. 4, IMR Final Determination dated January 12, 2022, pp. 8; Ex. 1, Dr. Ahmed's June 14, 2021 Report, pp. 2-11.)

ADJ12704660 · June 13, 2022

What the panel ordered

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The facts that decided it

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