ADJ6840627 · March 17, 2025

The Appeals Board found that EDD's lien recovery is not barred by payment for nonindustrial injury and deferred final decision for further review.

From the decision · page 6Lastly, as to defendant's argument that EDD may not recover on its lien because it paid benefits for a nonindustrial injury, we note that if our inquiry as to whether QME Dr. Schneider's reporting constitutes substantial medical evidence as to the period of temporary disability, EDD would be entitled to recover its lien irrespective of whether or not EDD paid benefits for a nonindustrial injury. (See Labor Code § 4904.) Hence, we will order that a final decision after reconsideration is deferred pending further review of the merits of this issue.

The Appeals Board preliminarily found issues with the QME Dr. Schneider's AMA Guides application and raised the possibility that the injury may result in permanent total disability under Labor Code section 4662(a)(4), deferring final decision for further review.

From the decision · page 3II. We turn first to defendant's contention that the WCJ erroneously found that applicant's injury resulted in permanent partial disability of 65% because QME Dr. Schneider's reporting misapplied the AMA Guides. Specifically, defendant argues that QME Dr. Schneider's reporting deviated from the Guides and failed to rebut the presumption that applicant's cognitive impairment should be rated strictly under the Guides.

The Appeals Board found unclear whether Utilization Review was properly followed and deferred final decision for further review.

From the decision · page 6Turning to defendant's argument that the WCJ erroneously found that applicant was entitled to reimbursement for self-procured chiropractic treatment because the treatment was not authorized under Utilization Review, we note that the parties raised the issue of "[l]iability for self-procured medical treatment" without reference to Utilization Review and without submitting Utilization Review documents for admission in evidence. It is thus unclear whether a Request for Authorization (RFA) was submitted and, if so, whether defendant reserved its right to retrospective Utilization Review by issuing a written decision complying with AD Rule 9792.9(b)(1). (Cal. Code Regs., tit. 8, § 9792.9(b)(1).) Hence, we will order that a final decision after reconsideration is deferred pending further review of the merits of this issue.

The Appeals Board found conflicting evidence on the average weekly wage and rejected use of current minimum wage for calculating temporary disability rate, deferring final decision for further review.

The Appeals Board noted lack of substantial medical evidence supporting temporary disability period beyond 104 weeks statutory limit and deferred final decision for further review.

From the decision · page 6We turn next to defendant's contention that the WCJ erroneously found that applicant was temporarily disabled from January 10, 2006 through April 23, 2017, because the record lacks substantial medical evidence demonstrating that she was temporarily disabled for the period.

Dr. Schneider reported traumatic brain injury with cognitive impairment and psychiatric sequela resulting in 55% permanent disability rating for brain and psyche injury.

Favours Applicant prevailed

This medical opinion formed the basis for the WCJ's permanent disability rating and was central to the Appeals Board's review.

From the decision · page 4Here, our preliminary review reveals that Dr. Schneider reported that applicant sustained a traumatic brain injury which resulted in cognitive brain impairment and psychiatric sequela which diminished her ability to perform activities of daily living and excluded her from participating in the labor market. Applicant's traumatic brain injury and consequent injury to the psyche received a permanent disability rating of 55%. The WCJ combined this permanent disability rating with the

Favours Defendant prevailed

This wage calculation discrepancy affected the temporary disability indemnity rate determination and was a key issue for reconsideration.

The record lacks substantial medical evidence supporting temporary disability beyond the 104 weeks statutory limit.

Favours Defendant prevailed

This fact challenges the WCJ's finding on the temporary disability period and supports deferral for further review.

From the decision · page 6Our preliminary review does not reveal argument from defendant or a record from the WCJ regarding the legal basis for finding a temporary disability period in excess of the 104 weeks statutory limit allowed after commencement of temporary disability payments. (See Lab. Code, § 4656(c)(1).) We also note that if the 104-week limit of Labor Code section 4656(c)(1) restricts the period for which applicant is entitled to temporary disability indemnity, then the WCJ's finding that the appropriate date for commencement of permanent disability payments was April 24, 2017, would be in error. Hence, we will order that a final decision after reconsideration is deferred pending further review of the merits of this issue.

Reported traumatic brain injury resulting in cognitive impairment and psychiatric sequela, with a 55% permanent disability rating for brain and psyche injury.

The Appeals Board preliminarily reviewed Dr. Schneider's report and found issues with the AMA Guides application but acknowledged the traumatic brain injury and psychiatric sequela rating.

From the decision · page 4Here, our preliminary review reveals that Dr. Schneider reported that applicant sustained a traumatic brain injury which resulted in cognitive brain impairment and psychiatric sequela which diminished her ability to perform activities of daily living and excluded her from participating in the labor market. Applicant's traumatic brain injury and consequent injury to the psyche received a permanent disability rating of 55%. The WCJ combined this permanent disability rating with the

Almaraz v. Environmental Recovery Services/Guzman v. Milpitas Unified School District (2009) 74 Cal.Comp.Cases 1084

Permanent disability rating must be based on AMA Guides but allows physician's clinical judgment for complex cases.

The Appeals Board reviewed whether Dr. Schneider's rating complied with AMA Guides and clinical judgment standards.

From the decision · page 4In Almaraz v. Environmental Recovery Services/Guzman v. Milpitas Unified School District (2009) 74 Cal.Comp.Cases 1084, 1086 (Appeals Board en banc) (Almaraz/Guzman II).), the Appeals Board stated that "when determining an injured employee's WPI, it is not permissible to go outside the four comers of the AMA Guides; however, a physician may utilize any chapter, table, or method in the AMA Guides that most accurately reflects the injured employee's impairment. (Id. at p. 1086.)

Milpitas Unified School District v. Workers' Comp. Appeals Bd. (2010) 187 Cal.App.4th 808

The AMA Guides recognize limitations and allow clinical judgment for complex impairments.

The Appeals Board cited this case to support the allowance of clinical judgment in impairment ratings.

From the decision · page 4In Milpitas Unified School District v. Workers' Comp. Appeals Bd. (2010) 187 Cal.App. 4th 808 [75 Cal.Comp.Cases 837] (Almarez/Guzman III), the Court found that the overarching goal of rating permanent impairment is to achieve accuracy, stating:

QME Dr. Schneider's reporting on cognitive impairment and psychiatric sequela

From the decision · page 4Here, our preliminary review reveals that Dr. Schneider reported that applicant sustained a traumatic brain injury which resulted in cognitive brain impairment and psychiatric sequela which diminished her ability to perform activities of daily living and excluded her from participating in the labor market. Applicant's traumatic brain injury and consequent injury to the psyche received a permanent disability rating of 55%. The WCJ combined this permanent disability rating with the