ADJ13556902 · June 16, 2023

The WCJ erred by relying solely on QME reports without addressing the stipulated injury AOE/COE and by failing to consider the defendant's lack of utilization review evidence; the Appeals Board found the record incomplete and remanded for further proceedings.

From the decision · page 1Lien claimant (Medland Medical) seeks reconsideration of the Joint Findings and Order(F&O) issued by the workers' compensation administrative law judge (WCJ) on March 22, 2023 wherein the WCJ found that the reporting of Medland Medical did not qualify as medical- legal reporting and was not necessary to relieve or cure applicant's industrial injuries, and ordered that lien claimant take nothing by way of their lien.

Applicant sustained specific injury to neck and lumbar spine arising out of and in the course of employment (AOE/COE) as stipulated by parties.

Favours Applicant prevailed

Supports lien claimant's entitlement to reimbursement for medical treatment related to the industrial injury.

From the decision · page 2I. In this case, the WCJ relies primarily on the reporting of the QME in finding that the treatment provided by lien claimant between January 3, 2022 through July 29. 2022 was not reasonable and necessary. We find this analysis incomplete. Specifically, the record contains substantial evidence that applicant suffered specific injury to her neck and lumbar spine arising out of and in the course of employment (AOE/COE). (Supplemental QME Report dated April 13, 2022 of Dr. Augustine Amerigo, DC, p. 5 ("the subject medical records contain substantial evidence that a specific work-related injury, resulting in medical care and temporary work restriction/duty modification, occurred on 08/27/2018.").). In the Compromise and Release dated August 3, 2022, the parties agreed that AOE/COE was "not at issue for neck and lumbar spine." (Compromise & Release, p.

Defendant failed to submit evidence of utilization review disputing lien claimant's treatment.

Favours Applicant prevailed

WCJ erred in finding treatment not reasonable or necessary without utilization review evidence; remand required for further proceedings.

From the decision · page 3that the treatment provided by lien claimant was not reasonable or necessary based on her review of the QME report. However, the appropriate way for a defendant to dispute whether treatment is reasonable and necessary is through UR, and here, defendant submitted no evidence that it had considered the RFAs from lien claimant and proceeded with the UR process. (See Lab. Code, § 4610.) Moreover, as noted above, the record indicates that applicant sustained injury to their neck and back, and the WCJ failed to address the issue of AOE/COE or find that applicant sustained injury AOE/COE in accordance with the parties' stipulation.

The subject medical records contain substantial evidence that a specific work-related injury, resulting in medical care and temporary work restriction/duty modification, occurred on 08/27/2018.

Supports the existence of a specific work-related injury AOE/COE to neck and lumbar spine relevant to lien treatment necessity.

From the decision · page 2I. In this case, the WCJ relies primarily on the reporting of the QME in finding that the treatment provided by lien claimant between January 3, 2022 through July 29. 2022 was not reasonable and necessary. We find this analysis incomplete. Specifically, the record contains substantial evidence that applicant suffered specific injury to her neck and lumbar spine arising out of and in the course of employment (AOE/COE). (Supplemental QME Report dated April 13, 2022 of Dr. Augustine Amerigo, DC, p. 5 ("the subject medical records contain substantial evidence that a specific work-related injury, resulting in medical care and temporary work restriction/duty modification, occurred on 08/27/2018.").). In the Compromise and Release dated August 3, 2022, the parties agreed that AOE/COE was "not at issue for neck and lumbar spine." (Compromise & Release, p.

Lab. Code, 4600

An employer must provide reasonable medical treatment to cure or relieve effects of industrial injury; if employer refuses, liable for reasonable expenses incurred by employee (Lab. Code, 4600).

Applied to determine reasonableness and necessity of lien claimant's medical treatment.

From the decision · page 2II. An employer must provide an injured worker with medical treatment to cure or relieve the injured worker from the effects of an industrial injury. (Lab. Code, § 4600.) Timely provision of reasonable medical treatment is an essential element of workers' compensation. (Cal. Const., Article XIV, § 4; McCoy v. Industrial Acc. Com. (1966) 64 Cal.2d 82, 87 [31 Cal.Comp.Cases 93]; Zeeb v. Workmen's Comp. Appeals Bd. (1967) 67 Cal.2d 496, 501 [32 Cal.Comp.Cases 441]; Braewood Convalescent Hosp. v. Workers' Comp. Appeals Bd. (Bolton) (1983) 34 Cal.3d 159, 165 [48 Cal.Comp.Cases 566]; see also, Lab. Code, § 4600.) If the employer neglects or refuses to provide reasonable medical care, "the employer is liable for reasonable expense incurred by or on behalf of the employee in providing treatment." (Lab. Code, § 4600(a).) Here, the WCJ determined

Lab. Code, 4610

Disputes over medical treatment reasonableness must be addressed through utilization review process (Lab. Code, 4610).

Noted defendant did not submit utilization review evidence disputing lien treatment.

From the decision · page 3that the treatment provided by lien claimant was not reasonable or necessary based on her review of the QME report. However, the appropriate way for a defendant to dispute whether treatment is reasonable and necessary is through UR, and here, defendant submitted no evidence that it had considered the RFAs from lien claimant and proceeded with the UR process. (See Lab. Code, § 4610.) Moreover, as noted above, the record indicates that applicant sustained injury to their neck and back, and the WCJ failed to address the issue of AOE/COE or find that applicant sustained injury AOE/COE in accordance with the parties' stipulation.

Torres v. AJC Sandblasting (2012) 77 Cal.Comp.Cases 1113 (Appeals Board en banc)

Lien claimants bear burden to prove medical treatment liens are reasonable and necessary (Torres v. AJC Sandblasting (2012)).

Applied to burden of proof for lien claimant's medical treatment charges.

From the decision · page 3Lien claimants hold the burden of proof to establish entitlement to reimbursement for medical treatment liens. (Torres v. AJC Sandblasting (2012) 77 Cal.Comp.Cases 1113 (Appeals Board en banc).) This burden includes the burden to show that specific treatments and the charges for those treatments were reasonable and necessary. (Id. at 1121.)

Applicant sustained injury AOE/COE to neck and back as stipulated by parties.

From the decision · page 2I. In this case, the WCJ relies primarily on the reporting of the QME in finding that the treatment provided by lien claimant between January 3, 2022 through July 29. 2022 was not reasonable and necessary. We find this analysis incomplete. Specifically, the record contains substantial evidence that applicant suffered specific injury to her neck and lumbar spine arising out of and in the course of employment (AOE/COE). (Supplemental QME Report dated April 13, 2022 of Dr. Augustine Amerigo, DC, p. 5 ("the subject medical records contain substantial evidence that a specific work-related injury, resulting in medical care and temporary work restriction/duty modification, occurred on 08/27/2018.").). In the Compromise and Release dated August 3, 2022, the parties agreed that AOE/COE was "not at issue for neck and lumbar spine." (Compromise & Release, p.

Defendant submitted no evidence of utilization review process disputing lien claimant's treatment.

From the decision · page 3that the treatment provided by lien claimant was not reasonable or necessary based on her review of the QME report. However, the appropriate way for a defendant to dispute whether treatment is reasonable and necessary is through UR, and here, defendant submitted no evidence that it had considered the RFAs from lien claimant and proceeded with the UR process. (See Lab. Code, § 4610.) Moreover, as noted above, the record indicates that applicant sustained injury to their neck and back, and the WCJ failed to address the issue of AOE/COE or find that applicant sustained injury AOE/COE in accordance with the parties' stipulation.