What the panel ordered
Findings and Award affirmed except as amended: applicant entitled to reimbursement for self-procured medical treatment at the amount provided by the Official Medical Fee Schedule; matter returned to trial level for determination of amount due under OMFS.
Defendant sought reconsideration of the December 6, 2019 Findings and Award regarding reimbursement for self-procured medical treatment expenses related to an authorized surgery.
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.
Applicant is entitled to reimbursement for self-procured medical treatment, but only at the amount provided by the OMFS, as defendant was not required to pre-pay or pay in excess of OMFS for authorized treatment.
From the decision · page 5FINDINGS OF FACT 6. Applicant is entitled to reimbursement for self-procured medical treatment at the amount provided by the Official Medical Fee Schedule. The issue of reimbursement for self-procured care is deferred with jurisdiction reserved at the trial level.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant authorized the surgery and made travel arrangements for applicant, but did not pre-pay the surgeon.
Favours Defendant prevailed
Showed that defendant did not neglect or refuse to provide medical treatment, so reimbursement is limited to OMFS.
Applicant paid for surgery expenses out-of-pocket and sought reimbursement.
Favours Applicant prevailed
Established applicant's entitlement to reimbursement, but not in excess of OMFS.
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.
Opined that the surgery recommended by Dr. Stone was medically reasonable.
Cited as basis for finding surgery was reasonable and authorized.
From the decision · page 2On February 9, 2016, Dr. Wood opined that a procedure recommended by Dr. Stone, "including left knee medial meniscal allograft with microfracture stem cell release, and bone marrow aspiration is medically reasonable." (Exh. Y, February 9, 2016, Richard I. Woods, M.D., Agreed Medical Evaluation Report, p.16.) Defendant authorized the surgery.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Lab. Code, § 4600; Lab. Code, § 4603.2; Lab. Code, § 5307.1; Adventist Health v. WCAB (Fletcher) (2012) 211 Cal.App.4th 376
Reimbursement for self-procured medical treatment is limited to the amount provided by the Official Medical Fee Schedule (OMFS), regardless of whether the applicant or provider seeks reimbursement.
Applied to limit applicant's reimbursement to OMFS amount for authorized surgery.
From the decision · page 4Section 5307.1 requires the administrative director to adopt and revise the OMFS for "medical services other than physician services...and all other treatment, care, services and goods described in Section 4600." (Lab. Code, § 5307.1.) Effective January 1, 2014, the administrative director added a rule outlining how to calculate reimbursement for unlisted procedures. (Cal. Code Regs., § 9789.12.4.) While the process for determining whether a fee is reasonable differs depending on whether an applicant or provider is seeking reimbursement, the fee allowed by the OMFS remains the same. Neither section 5307.1 nor section 4600 provides that the reasonableness of a fee is determined differently if an applicant rather than a medical provider is seeking reimbursement.
What proof carried it
The evidence the panel weighed, by kind.
Defendant's bill review expert testimony regarding OMFS amount.
Applicant's testimony regarding payment for surgery and understanding of authorization.
The same issues, filtered across the whole corpus — or paste your own facts and let the search rank by factor match.
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.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
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