ADJ15815443 — California WCAB decision

What the panel ordered

The WCAB granted reconsideration, rescinded the WCJ's August 18, 2025 Findings and Order, and returned the matter to the trial level for further proceedings consistent with the opinion.

Applicant sought reconsideration of the WCJ's Findings of Fact and Order issued August 18, 2025, which denied her claim for industrial injury; the WCJ found applicant failed to prove injury AOE/COE and ordered applicant to take nothing; the WCJ also found medical-legal expenses payable by defendant; the WCJ's decision was rescinded and the case returned for further proceedings.

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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.

AOE/COERemandedback · right shoulder

The WCJ's decision was rescinded because it failed to provide adequate analysis, did not apply the law properly, and did not identify substantial medical evidence supporting the denial of injury AOE/COE. The QME's reports were found to be based on significant factual errors and thus not substantial evidence. Additional medical development was required.

From the decision · page 1Applicant seeks reconsideration of the Findings of Fact and Order (F&O), issued by the workers' compensation administrative law judge (WCJ) on August 18, 2025, wherein the WCJ found in pertinent part that applicant was employed as registered nurse by defendant during the time period September 30, 2001 through January 25, 2019; that she failed to meet her burden to prove that she sustained industrial injury to her back arising out of and in the course of her employment (AOE/COE); and that applicant incurred reasonable and necessary medical-legal expenses payable by defendant; and the WCJ ordered that applicant take nothing.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

The WCJ's Opinion failed to provide adequate analysis, did not apply the law properly, and did not identify substantial medical evidence supporting the denial of injury AOE/COE.

Favours Applicant prevailed

This failure led to the rescission of the WCJ's Findings and Order and the remand for further proceedings.

From the decision · page 10Secondly, the Opinion did not adequately address the "reasons or grounds upon with the determination was made," as required by section 5313. The Opinion simply listed the evidence in the case and then concluded that applicant "failed to meet her burden of proving she sustained industrial injury to her back arising out of and in the course of her employment with defendant." (OOD, at p. 1.) What is missing is any discussion of or citation to the specific evidence relied upon in reaching this conclusion, as well as a discussion of the relevant law, and an application of the

The QME's reports contained significant factual errors, including misidentifying the employer at the time of a 2005 injury, undermining the reliability of his opinions.

Favours Applicant prevailed

These errors rendered the QME's opinions not substantial medical evidence, necessitating further medical development and replacement of the QME.

From the decision · page 15Here, neither the QME's reporting, nor that of the PTP, constitute substantial medical evidence. The QME's reporting--including his written reports and his depositions--are not substantial medical evidence due to the QME's repeated reliance on significant mistakes of fact. (Escobedo, supra, 70 Cal.Comp.Cases at p. 621 [To constitute substantial evidence "... a medical opinion...must not be speculative, it must be based on pertinent facts and on an adequate examination and history, and it must set forth reasoning in support of its conclusions."].) The first significant mistake of fact is the QME's repeated assertion that applicant's 2005 back injury was non-industrial, because she was not working for defendant when she was injured. (Defendant's Exhs. A, at pp. 30, 32; B, at p. 2; C, at p. 2; D at p. 2.) In fact, as the QME acknowledged elsewhere in his report, applicant was employed by defendant at the time of the 2005 injury. (Defendant's Exh. A, at pp. 3, 26.) The QME mixed up the hospital where applicant was treated with applicant's employer, and repeatedly relied on this erroneous information to conclude that applicant's back injury was non-industrial.

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.

QMERejected · Orthopedics

Dr. Ahearn opined that applicant's injuries were non-industrial, but his reports were found to contain significant factual errors, including misidentifying the employer at the time of a 2005 injury, undermining the reliability of his opinions.

The WCAB found Dr. Ahearn's reports inaccurate, inconsistent, and incomplete due to repeated factual errors, and thus not substantial medical evidence.

From the decision · page 15Here, neither the QME's reporting, nor that of the PTP, constitute substantial medical evidence. The QME's reporting--including his written reports and his depositions--are not substantial medical evidence due to the QME's repeated reliance on significant mistakes of fact. (Escobedo, supra, 70 Cal.Comp.Cases at p. 621 [To constitute substantial evidence "... a medical opinion...must not be speculative, it must be based on pertinent facts and on an adequate examination and history, and it must set forth reasoning in support of its conclusions."].) The first significant mistake of fact is the QME's repeated assertion that applicant's 2005 back injury was non-industrial, because she was not working for defendant when she was injured. (Defendant's Exhs. A, at pp. 30, 32; B, at p. 2; C, at p. 2; D at p. 2.) In fact, as the QME acknowledged elsewhere in his report, applicant was employed by defendant at the time of the 2005 injury. (Defendant's Exh. A, at pp. 3, 26.) The QME mixed up the hospital where applicant was treated with applicant's employer, and repeatedly relied on this erroneous information to conclude that applicant's back injury was non-industrial.

PTPRejected · Orthopedics

Dr. Lavi opined that applicant's injuries were industrial but his reports were incomplete as he did not review most medical records.

Dr. Lavi's reports were incomplete and thus not substantial medical evidence because he did not review most of the medical records.

From the decision · page 16The primary treating physician, Dr. Lavi's reporting also does not constitute substantial medical evidence. Most of his reports entered into evidence are treatment records, which do address the question of causation of applicant's cumulative trauma injuries. (Applicant's Exh. 2, at pp. 1-55.) Two of Dr. Lavi's reports, the PTP's Initial Complex Orthopedic Evaluation, and the August 27, 2024 rebuttal report, address causation, but are incomplete because Dr. Lavi was not provided, and thus did not review, most of applicant's medical records. (Applicant's Exh. 2, at pp. 62, 65; Applicant's Exh. 1, at pp. 2-5.)

The rules the panel named

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

Labor Code section 5313

The WCJ must provide findings with reasons or grounds upon which the determination was made, including a summary of evidence and application of law to facts, per Labor Code section 5313.

The WCJ's Opinion was found skeletal and insufficient for failing to provide adequate analysis and application of law to facts.

From the decision · page 10Secondly, the Opinion did not adequately address the "reasons or grounds upon with the determination was made," as required by section 5313. The Opinion simply listed the evidence in the case and then concluded that applicant "failed to meet her burden of proving she sustained industrial injury to her back arising out of and in the course of her employment with defendant." (OOD, at p. 1.) What is missing is any discussion of or citation to the specific evidence relied upon in reaching this conclusion, as well as a discussion of the relevant law, and an application of the

Escobedo v. Marshalls (2005) 70 Cal.Comp.Cases 604, 621 (Appeals Bd. en banc)

Medical opinion must be framed in terms of reasonable medical probability, based on pertinent facts and adequate examination, and set forth reasoning in support of conclusions to constitute substantial evidence.

The QME's reports were found not to constitute substantial evidence due to factual errors and lack of adequate reasoning.

From the decision · page 15Here, neither the QME's reporting, nor that of the PTP, constitute substantial medical evidence. The QME's reporting--including his written reports and his depositions--are not substantial medical evidence due to the QME's repeated reliance on significant mistakes of fact. (Escobedo, supra, 70 Cal.Comp.Cases at p. 621 [To constitute substantial evidence "... a medical opinion...must not be speculative, it must be based on pertinent facts and on an adequate examination and history, and it must set forth reasoning in support of its conclusions."].) The first significant mistake of fact is the QME's repeated assertion that applicant's 2005 back injury was non-industrial, because she was not working for defendant when she was injured. (Defendant's Exhs. A, at pp. 30, 32; B, at p. 2; C, at p. 2; D at p. 2.) In fact, as the QME acknowledged elsewhere in his report, applicant was employed by defendant at the time of the 2005 injury. (Defendant's Exh. A, at pp. 3, 26.) The QME mixed up the hospital where applicant was treated with applicant's employer, and repeatedly relied on this erroneous information to conclude that applicant's back injury was non-industrial.

ADJ15815443 · December 9, 2025

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

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The rules the panel named

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