ADJ9046738 · October 3, 2025

The WCAB granted reconsideration to allow further review of the merits and the entire record due to unresolved factual and legal issues regarding utilization review and medical necessity.

From the decision · page 10Although we have preliminarily considered the Petition for Reconsideration, the WCJ's Report, and the record in this matter, we are not persuaded that the record is properly developed on one or more of the above issues, including whether there was a timely made and timely communicated UR determination for each of Dr. Foxley's RFAs, and if not, how the MTUS applies to each specific request for treatment. Accordingly, taking into account the statutory time constraints for acting on the petitions, and based upon our initial review of the record, we believe reconsideration must be granted to allow sufficient opportunity to further study the factual and legal issues in this case. Thereafter, a final decision after reconsideration will be issued by the Appeals Board, from which any aggrieved person may timely seek a writ of review pursuant to Labor Code section 5950 et seq.

Defendants failed to provide Dr. William Foxley with the correct fax number for utilization review, resulting in failure to timely submit RFAs for medical treatment.

Favours Applicant prevailed

This failure led to the WCJ finding that medical treatment in the RFAs was reasonable and necessary and justified sanctions against defendants, supporting granting reconsideration.

From the decision · page 1Defendant seeks removal and/or reconsideration of the June 30, 2025 Findings of Fact, Award, and Orders, wherein the workers' compensation administrative law judge (WCJ) found, as stipulated by the parties, that applicant sustained a cumulative trauma during the period of July 25, 2012 to July 12, 2013 to sleep, neck, bilateral knees, bilateral arms, bilateral hands/fingers, bilateral wrists, entire back, bilateral shoulders, and bilateral legs arising out of and in the course of employment as a driver by employer Donaghy Sales, LLC, insured by Sentinel Insurance Company, Ltd. Administered by Gallagher Bassett. The WCJ also found that the defendants in this case failed to provide treating physician Dr.

Prepared RFAs for medical treatment; defendants failed to provide correct fax number for utilization review, causing delays in processing RFAs.

The WCJ found that defendants failed to provide Dr. Foxley with the correct fax number for submission of RFAs, leading to delays and failure to timely conduct utilization review.

From the decision · page 1Defendant seeks removal and/or reconsideration of the June 30, 2025 Findings of Fact, Award, and Orders, wherein the workers' compensation administrative law judge (WCJ) found, as stipulated by the parties, that applicant sustained a cumulative trauma during the period of July 25, 2012 to July 12, 2013 to sleep, neck, bilateral knees, bilateral arms, bilateral hands/fingers, bilateral wrists, entire back, bilateral shoulders, and bilateral legs arising out of and in the course of employment as a driver by employer Donaghy Sales, LLC, insured by Sentinel Insurance Company, Ltd. Administered by Gallagher Bassett. The WCJ also found that the defendants in this case failed to provide treating physician Dr.

Labor Code section 4610(i)(1)

Labor Code section 4610(i)(1) regarding timely utilization review of medical treatment requests.

The WCJ and WCAB considered whether utilization review was timely conducted for each RFA and the applicability of the Medical Treatment Utilization Schedule (MTUS).

From the decision · page 7III. We highlight several legal principles that may be relevant to our review of this matter. First, as noted by the WCJ, section 4610, subsection (i)(1) governs the timeline for UR of a physician's RFA of current or future treatment. That subsection provides, in relevant part:

Labor Code section 5903

Labor Code section 5903 grounds for petition for reconsideration.

The petition for reconsideration was evaluated under the grounds set forth in Labor Code section 5903.

From the decision · page 10IV. The grounds for a petition for reconsideration are set forth in Labor Code section 5903:

Defendants failed to provide correct fax number to Dr. Foxley for utilization review, causing delays and failure to timely process RFAs.

From the decision · page 1Defendant seeks removal and/or reconsideration of the June 30, 2025 Findings of Fact, Award, and Orders, wherein the workers' compensation administrative law judge (WCJ) found, as stipulated by the parties, that applicant sustained a cumulative trauma during the period of July 25, 2012 to July 12, 2013 to sleep, neck, bilateral knees, bilateral arms, bilateral hands/fingers, bilateral wrists, entire back, bilateral shoulders, and bilateral legs arising out of and in the course of employment as a driver by employer Donaghy Sales, LLC, insured by Sentinel Insurance Company, Ltd. Administered by Gallagher Bassett. The WCJ also found that the defendants in this case failed to provide treating physician Dr.