ADJ14015513 · April 13, 2026

The medical evidence was unanimous that the applicant requires 24/7 home attendant care as reasonably necessary to cure or relieve the effects of the industrial injury, supported by the primary treating physician Dr. Lo, the AME Dr. Munday, and a Life Care Plan. The defendant's contention that the RFA was incomplete and the Utilization Review was validly denied was rejected as invalid and untimely, allowing the WCJ to determine medical necessity.

From the decision · page 1Defendant seeks reconsideration of the Findings of Fact, Award and Opinion on Decision (F&A) issued on January 7, 2026, wherein the workers' compensation administrative law judge (WCJ) found that (1) while employed on October 5, 2020, applicant sustained injury arising out of and in the course of employment to the femur, bruised lung, and in the form of a traumatic brain injury; (2) the employer has furnished some medical treatment, and the primary treating physician is Dr. Timothy Lo; (3) there has not been a timely Utilization Review (UR) denial of the August 20, 2025 Request For Authorization (RFA) from Dr. Lo for 24 hours per day, 7 days per week of home attendant care; and (4) the requested treatment in the form of home attendant care is reasonable and necessary to cure or relieve applicant from the effects of industrial injury.

The primary treating physician Dr. Lo requested 24/7 home attendant care based on review of the AME's deposition and Life Care Plan.

Favours Applicant prevailed

This established the medical necessity and reasonableness of the requested treatment.

From the decision · page 4On 8/20/2025, the treating physician, Dr. Lo, filed an RFA requesting authorization for home attendant care for the applicant at a frequency of 24 hours a day, 7 days a week (Applicant's Exhibit 3). In his report of 8/12/2025, Dr. Lo stated, "With this supplemental report, I will make formal request/RFA for 24/7 attendant care, as also recommended by Certified Life Care Planner Tracy Albee, R.N., in her report dated November 25, 2024" (Applicant's Exhibit 2). A condensed version of this report, also dated 8/12/25, was attached to the 8/20/25 RFA.

The AME Dr. Munday found the applicant permanently mentally incapacitated requiring supervision for most activities of daily living with no expected significant improvement.

Favours Applicant prevailed

This supported the permanence and extent of the applicant's need for attendant care.

From the decision · page 5The AME, Dr. Munday, told the parties that the applicant had a severe cognitive impairment, particularly with respect to memory (Applicant's Exhibit 5, page 15:15-25; 6:1). The AME further agreed that the applicant was permanently mentally incapacitated and required supervision for most activities of daily living (Exhibit 5, page 14: 1-12). At that point in time, four and a half years post injury,

Defendant's response to the RFA was unsigned, cited no valid legal authority, and improperly stopped Utilization Review.

Favours Applicant prevailed

This procedural defect rendered the issue of medical necessity subject to WCAB determination, favoring the applicant.

From the decision · page 5In summary, the response by petition[er] in the form of their 8/25/25 Notice (Joint Exhibit AA) is invalid both because it is unsigned, and because it cites no valid legal authority in support.... In addition, the medical record attached to the RFA in question by Dr. Lo does in fact reference as a basis for his request, other medical records which do provide in detail the scope and extent of the home care needed. Whoever it was at petitioner's office that authored Joint Exhibit AA needed to be willfully ignorant of the medical record to complain about a lack of specificity in the RFA. Summary rejection of the RFA without UR, by some un-named person or entity without medical expertise, citing non-existent legal authority, and opining upon a medical issue they are not qualified to address, is not timely UR review. No UR review is untimely review.

Dr. Lo requested 24/7 home attendant care based on review of the AME's deposition and the Life Care Plan, supporting the need for ongoing care as medically necessary.

Dr. Lo's reports and RFA were supported by the Life Care Plan and AME's deposition, establishing medical necessity for 24/7 care.

From the decision · page 4On 8/20/2025, the treating physician, Dr. Lo, filed an RFA requesting authorization for home attendant care for the applicant at a frequency of 24 hours a day, 7 days a week (Applicant's Exhibit 3). In his report of 8/12/2025, Dr. Lo stated, "With this supplemental report, I will make formal request/RFA for 24/7 attendant care, as also recommended by Certified Life Care Planner Tracy Albee, R.N., in her report dated November 25, 2024" (Applicant's Exhibit 2). A condensed version of this report, also dated 8/12/25, was attached to the 8/20/25 RFA.

Dr. Munday found the applicant permanently mentally incapacitated requiring supervision for most activities of daily living, with no expected significant improvement.

Dr. Munday's deposition established the severity and permanence of the applicant's cognitive impairment, supporting the need for ongoing attendant care.

From the decision · page 5The AME, Dr. Munday, told the parties that the applicant had a severe cognitive impairment, particularly with respect to memory (Applicant's Exhibit 5, page 15:15-25; 6:1). The AME further agreed that the applicant was permanently mentally incapacitated and required supervision for most activities of daily living (Exhibit 5, page 14: 1-12). At that point in time, four and a half years post injury,

Labor Code section 4600

Employers must provide medical treatment reasonably required to cure or relieve the injured worker from the effects of injury under Labor Code section 4600.

The applicant's need for 24/7 home attendant care was found reasonable and necessary to cure or relieve effects of injury.

From the decision · page 12Under section 4600, an employer must provide "[m]edical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." (§ 4600 (a).) It is well-settled that home health care is an appropriate benefit under section 4600, and that home health care services need not be provided by a nursing professional to be compensable. (Henson v. Workers' Comp. Appeals Bd. (1972) 27 Cal.App.3d 452 (awarding compensation to wife of injured worker who provided home healthcare to injured worker); Smyers v. Workers' Comp. Appeals Bd. (1984) 157 Cal. App. 3d 36, 42 (housekeeping services reimbursable where they are "necessary and reasonable in order to allow the injured worker to fully comply with the treatment prescribed by [the applicant's] physician"); Hodgman v. Workers' Comp. Appeals Bd. (2007) 155 Cal.App.4th 44 [72 Cal.Comp.Cases 1202] (mother of injured worker, who was also his conservator, could be reimbursed for monitoring and managing her son's health care needs); see also Neri Hernandez v. Geneva Staffing, Inc. dba Workforce Outsourcing, Inc. (2014) 79 Cal.Comp.Cases 682 (en banc).)

Labor Code section 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230

Utilization Review (UR) ensures medical decisions are made by physicians, not claims adjusters, and defects in UR allow WCAB to determine medical necessity.

Defendant's invalid and untimely UR response allowed WCJ to determine medical necessity.

From the decision · page 9II. Under California's workers' compensation system, the employer of an industrially injured employee is responsible for all medical treatment reasonably necessary to cure or relieve the injured employee from the effects of his or her injury. (§ 4600.) Employers' responses to requests for medical treatment submitted by the physicians of their injured employees are governed by UR, the legislative purpose of which is to "ensure quality, standardized medical care for workers in a prompt and expeditious manner"... so that "a physician rather than a claims adjustor with no medical training, makes the decision to deny, delay or modify treatment." (§ 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 241 [73 Cal.Comp.Cases 981].) UR does not abrogate an employer's duties to provide reasonable medical treatment to cure or relieve from the effects of the industrial injury and to investigate whether and to what extent treatment is due. (Cal. Code Regs., tit. 8, § 10109; § 4600(a); see Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd. (1983) 34 Cal.3d 159, 165 [48 Cal.Comp.Cases 566]) "[W]here the injured worker can demonstrate that the disputed utilization review determination suffers from... material procedural defects that undermine the integrity of the utilization review decision...

California Code of Regulations, title 8, section 9792.6.1(t)(2)

A request for authorization must be complete and signed by a treating physician under AD Rule 9792.6.1(t)(2).

Defendant's contention that the RFA was incomplete and justified denial of UR was rejected as invalid.

From the decision · page 9'the issue of medical necessity is not subject to IMR but is to be determined by the Workers' Compensation Appeals Board based upon substantial evidence, with the employee having the burden of proving the treatment is reasonably required.'" (Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 313 (Dubon I).) We turn first to defendant's contention that it issued a valid notice that applicant's RFA was incomplete under AD Rule 9792.6.1(t)(2), nullifying its obligation to complete UR until applicant's treating physician submitted a complete RFA. Preliminarily, we note that defendant's response to the RFA failed to assert an objection under AD Rule 9792.6.1(t)(2), and defendant did not raise the issue of whether the response was valid under AD Rule 9792.6.1(t)(2) for trial. (Report, pp. 2-3.) The sole issue concerning the validity of defendant's response at trial in the record before us is whether it was timely and signed by a doctor. (Minutes of Hearing (Reporter), November 18, 2025, p. 2:9-12.) Given that the issue

The medical evidence was unanimous in support of the need for 24/7 home attendant care, including the Life Care Plan and expert opinions.

From the decision · page 6Therefore, there is unanimity of opinion among the treaters and evaluators that the applicant would need this home attendant care as defined by the Life Care Plan, and that this need would be unlikely to change in any significant was in the future. There is no contrary medical opinion.