What the panel ordered
Petition for Reconsideration denied
Petition for Reconsideration of the Findings of Fact issued by the WCJ on December 8, 2020
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.
The IMR determination was upheld because the medical guidelines do not recommend medial branch blocks for radiculopathy pain syndromes, and the applicant did not prove grounds to set aside the determination by clear and convincing evidence.
From the decision · page 4On July 6, 2020, IMR upheld the utilization review decision. The clinical case summary provides that Applicant sustained an industrial injury in 1992 and received treatment for failed back syndrome, lumbar spine spondylosis, and altered gait due to kyphotic posture from using a walker. On May 12, 2020, Applicant complained of lower back pain radiating into the left lower extremity. The provider reported that an epidural steroid injection helped in the past. The IMR rationale cited MTUS Low Back Disorders 2019 Guidelines and indicated diagnostic lumbar facet injections are not recommended. (Exhibit BB)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
The medical guidelines (MTUS and Official Disability Guidelines) do not recommend medial branch blocks for radiculopathy pain syndromes.
Favours Defendant prevailed
This supported upholding the IMR determination denying the treatment request.
From the decision · page 5Applicant was diagnosed with failed back surgery syndrome with left lower extremity radiculopathy (Exhibit 8) and the Guidelines provides medial branch blocks are not recommended for radiculopathy pain syndromes and does not provide an exception related to posture or fall risks. The record and the Guidelines are consistent with the IMR determination and do not support a finding that the administrative director acted without or in excess of his powers or the determination was the result of a plainly erroneous finding of fact and the mistake is a matter of ordinary knowledge as alleged.
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.
Diagnosed applicant with failed back surgery syndrome with left lower extremity radiculopathy and noted altered gait from kyphotic posture and posture changes due to long-term use of a walker. Recommended medial branch blocks at L3, L4, and L5 bilaterally as part of treatment plan.
The opinion was considered in the context of the medical treatment request and IMR determination.
From the decision · page 3On May 12, 2020, Applicant saw Dr. David Miller at Napa Pain Institute where she complained of low back pain that occasionally radiates down the left lower extremity to the ankle. Applicant had steroid injections in the past that were very helpful. Her diagnoses included failed back surgery syndrome with left lower extremity radiculopathy, altered gait from kyphotic posture,
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code
Labor Code section 4610.6(h)
The Board held that resolving discrepancies between the MTUS and ODG is outside the scope of an IMR appeal under this section.
From the decision · page 1We have considered the allegations of applicant's Petition for Reconsideration, defendant's answer and the contents of the Report of the workers' compensation administrative law judge (WCJ) with respect thereto. Based on our review of the record, and for the reasons stated in the WCJ's Report, which we adopt and incorporate, we will deny reconsideration. Resolving discrepancies between the medical treatment utilization schedule (MTUS) and the Official Disability Guidelines (ODG) is outside the scope of an appeal of an independent medical review (IMR) determination under Labor Code section 4610.6(h). (Lab. Code, § 4610.6(h).)
What proof carried it
The evidence the panel weighed, by kind.
Applicant's medical records and the MTUS and Official Disability Guidelines consistently indicate medial branch blocks are not recommended for radiculopathy pain syndromes.
From the decision · page 5Applicant was diagnosed with failed back surgery syndrome with left lower extremity radiculopathy (Exhibit 8) and the Guidelines provides medial branch blocks are not recommended for radiculopathy pain syndromes and does not provide an exception related to posture or fall risks. The record and the Guidelines are consistent with the IMR determination and do not support a finding that the administrative director acted without or in excess of his powers or the determination was the result of a plainly erroneous finding of fact and the mistake is a matter of ordinary knowledge as alleged.
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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