ADJ882004 · February 2, 2026

The WCAB affirmed the WCJ's determination that the OMFS applies to the lien claimants' charges because the lien claimants failed to prove extraordinary circumstances justifying fees above OMFS, but deferred the issue of actual payment to lien claimants for further informal adjustment at trial level.

From the decision · page 9In summary, to the extent that lien claimants' usual and customary charges might be permissible under AD Rule 9792(c), we concur with the WCJ's determination that the record does not support the "extraordinary circumstances related to the unusual nature of the services rendered" necessary to justify fees in excess of the OMFS. Accordingly, we will affirm the WCJ's determination that the OMFS is applicable to lien claimants' charges herein. However, insofar as lien claimants' Petition raises a colorable dispute as to actual receipt of the OMFS reimbursement of its liens, an issue not submitted for decision from trial, we will rescind the WCJ's Findings of Fact that "defendant has paid the liens per the OMFS" and defer the issue. Upon return of this matter to the trial level, the parties may informally adjust issues attendant to the payment and receipt of the reimbursement at OMFS rates, with jurisdiction reserved to the WCJ in the event of further dispute.

Lien claimants did not prove extraordinary circumstances related to unusual nature of services rendered.

Favours Defendant prevailed

This failure meant fees above OMFS were not justified, affirming OMFS applicability.

From the decision · page 8Following our complete review of the record occasioned by lien claimants' petition, we agree with the WCJ's conclusion that lien claimants have not met their affirmative burden of establishing the existence of "extraordinary circumstances related to the unusual nature of the services rendered," justifying the award of fees exceeding OMFS. (Cal. Code Regs, tit. 8, § 9792, subd. (c).) We therefore concur with the WCJ's determination that the OMFS is applicable to the charges for services asserted by lien claimants.

No evidence of claim denial or compensability dispute at time of services; delay in payment not equivalent to denial.

Favours Defendant prevailed

This undermined lien claimants' argument for usual and customary charges above OMFS.

From the decision · page 8Lien claimants assert that the defendant's 12-year delay in payment of lien claimants' billing "demonstrates that both doctors treated on what was effectively a denied claim." (Petition, at p. 11:11.) However, we are not persuaded that a delay in payment to a medical provider is tantamount to a denial of compensability in the first instance. The submitted evidence does not reflect a claim denial notice, nor did lien claimants interpose witness testimony supporting a compensability dispute at the time the services were rendered. Nor does the record demonstrate how even a considerable delay in payment establishes the existence of the "extraordinary circumstances" related to the provision of "unusual services" as set forth in AD Rule 9792. We further agree with the WCJ that the educational background and professional accomplishments of lien claimants herein, although laudable, do not otherwise establish the existence of the type of extraordinary circumstances that would justify a departure from the OMFS. (Petition, at p. 17:25; Report, at p. 7.) And although the parties have stipulated that services provided by lien claimants were medically necessary, the evidentiary record does not reflect that the services were unusual services necessitated by or related to extraordinary circumstances.

Labor Code section 5307.1; Cal. Code Regs., tit. 8, 9792(c)

Official Medical Fee Schedule (OMFS) applies to medical lien charges unless extraordinary circumstances justify fees above OMFS.

The OMFS sets maximum fees; fees above OMFS require proof of extraordinary circumstances related to unusual services.

From the decision · page 5Section 5307.1 provides, in relevant part, for the adoption of an OMFS "that shall establish reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods described in Section 4600 and provided pursuant to this section." (Lab. Code, § 5307.1(a)(1), italics added.)

Labor Code sections 3202.5, 5705

Lien claimants bear burden of proof to show reasonableness of charges exceeding OMFS by preponderance of evidence.

Lien claimants must prove extraordinary circumstances to justify fees above OMFS.

From the decision · page 8A medical lien claimant has the burden of proving all the elements necessary for the establishment of its lien, and it must carry this burden by a preponderance of the evidence. (Lab. Code, § 5705 ["[t]he burden of proof rests upon the party or lien claimant holding the affirmative of the issue."]); Lab. Code, § 3202.5 ["[a]ll parties and lien claimants shall meet the evidentiary burden of proof on all issues by a preponderance of the evidence."]; Zenith Ins. Co. v. Workers' Comp. Appeals Bd. (Capi) (2006) 138 Cal.App.4th 373, 376§ 377 [71 Cal.Comp.Cases 374, 376§ 377]; Tapia v. Skill Master Staffing, supra, 73 Cal.Comp.Cases at pp. 1342§ 1343; Kunz v. Patterson Floor Covering, supra, 67 Cal.Comp.Cases at p. 1592.)

Lien claimants failed to prove extraordinary circumstances related to unusual nature of services to justify fees above OMFS.

From the decision · page 8Following our complete review of the record occasioned by lien claimants' petition, we agree with the WCJ's conclusion that lien claimants have not met their affirmative burden of establishing the existence of "extraordinary circumstances related to the unusual nature of the services rendered," justifying the award of fees exceeding OMFS. (Cal. Code Regs, tit. 8, § 9792, subd. (c).) We therefore concur with the WCJ's determination that the OMFS is applicable to the charges for services asserted by lien claimants.

No evidence of claim denial notice or compensability dispute at time of services rendered; delay in payment not equivalent to denial.

From the decision · page 8Lien claimants assert that the defendant's 12-year delay in payment of lien claimants' billing "demonstrates that both doctors treated on what was effectively a denied claim." (Petition, at p. 11:11.) However, we are not persuaded that a delay in payment to a medical provider is tantamount to a denial of compensability in the first instance. The submitted evidence does not reflect a claim denial notice, nor did lien claimants interpose witness testimony supporting a compensability dispute at the time the services were rendered. Nor does the record demonstrate how even a considerable delay in payment establishes the existence of the "extraordinary circumstances" related to the provision of "unusual services" as set forth in AD Rule 9792. We further agree with the WCJ that the educational background and professional accomplishments of lien claimants herein, although laudable, do not otherwise establish the existence of the type of extraordinary circumstances that would justify a departure from the OMFS. (Petition, at p. 17:25; Report, at p. 7.) And although the parties have stipulated that services provided by lien claimants were medically necessary, the evidentiary record does not reflect that the services were unusual services necessitated by or related to extraordinary circumstances.