What the panel ordered
The WCAB affirmed the Findings of Fact, Award, and Orders Admitting Evidence except that it amended the Findings of Fact to defer the issue of whether the treatment provided by Spine and Orthopedic Center was necessary and appropriate medical treatment to cure or relieve the effects of the cumulative injury. The Award of payment to the Spine and Orthopedic Center for medical treatment was deferred and the matter was returned to the WCJ for further proceedings.
Defendant Star Insurance Company sought reconsideration of the Findings of Fact, Award, and Orders Admitting Evidence issued by the WCJ on March 5, 2019. The WCJ had found that the applicant sustained an injury arising out of and in the course of employment and that defendants did not have control over applicant's medical treatment. The WCJ also found the medical treatment provided by lien claimant Spine and Orthopedic Center was reasonable and necessary. The WCJ recommended denial of the petition for reconsideration. The WCAB considered the petition and the WCJ's report and issued a decision after reconsideration.
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 WCAB deferred the issue of whether the treatment provided by Spine and Orthopedic Center was necessary and appropriate medical treatment because the Board lacks medical expertise to determine consistency with MTUS and Labor Code section 4604.5, and recommended further proceedings to address this issue.
From the decision · page 2We have considered the allegations in the Petition, and the contents of the Report. Based on our review of the record, for the reasons stated by the WCJ in the Report from page 3 to page 15, line 3, which we adopt and incorporate by this reference thereto, and for the reasons discussed below, we will affirm the F&A except that we will amend the F&A to defer the issues of whether the treatment that Spine and Orthopedic Center provided applicant was necessary and appropriate medical treatment to cure or relieve her from the effects of her cumulative injury. (Finding of Fact 7). Based thereon, we will amend the Award and return the matter to the WCJ for further proceedings consistent with this opinion.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Applicant sustained an injury arising out of and in the course of employment during the period from August 6, 2013, through June 2, 2015.
Favours Applicant prevailed
This fact established the compensable injury period relevant to the medical treatment dispute.
Favours Applicant prevailed
This fact was central to the dispute over medical control and the reasonableness and necessity of the treatment provided by the lien claimant.
The WCJ relied on substantial medical evidence in finding the lien claimant's medical treatment was necessary and appropriate.
Favours Applicant prevailed
This supported the WCJ's finding that the medical treatment was reasonable and necessary, favoring the applicant.
From the decision · page 7It is recommended that the pending petition be denied. The undersigned PWCJ appropriately held Petitioner to its burden of proof on alleged medical control via its MPN and relied on substantial medical evidence in finding Lien Claimant's medical treatment was necessary and appropriate.
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.
Dr. Falkinstein opined that the cervical spine, left shoulder, and lumbar spine impairments were largely due to the cumulative injury, with degenerative changes and obesity as non-industrial factors. He recommended further medical treatment including physical therapy and injections.
From the decision · page 11Yuri Falkinstein, M.D. is serving as the Qualified Medical Evaluator in the field of orthopedic surgery. He evaluated Applicant and provided a report dated November 21, 2015. Unfortunately, page three of Dr. Falkinstein's initial report regarding applicant appears to be have been replaced by page three of a report regarding an injured worker named Frank Guadiana (whom appears to have been examined by Dr. Falkinstein on the same day). Defendant's Exhibit B/Lien Claimant's Exhibit 07: Report of Yuri Falkinstein 11/21/2015 p. 3.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
In the absence of any one of the elements of authorization, compliance, and disclosure for MPN control, the injured worker has medical control and may self-procure necessary and appropriate treatment from a provider of his or her choice within a reasonable geographic area at the employer or carrier's expense. Medical providers may recover the costs of providing such treatment via a lien claim.
The WCJ held Petitioner to its burden of proof on alleged medical control via its MPN and found Lien Claimant's medical treatment was necessary and appropriate.
From the decision · page 7It is recommended that the pending petition be denied. The undersigned PWCJ appropriately held Petitioner to its burden of proof on alleged medical control via its MPN and relied on substantial medical evidence in finding Lien Claimant's medical treatment was necessary and appropriate.
What proof carried it
The evidence the panel weighed, by kind.
The WCJ appropriately held Petitioner to its burden of proof on alleged medical control via its MPN and relied on substantial medical evidence in finding Lien Claimant's medical treatment was necessary and appropriate.
From the decision · page 7It is recommended that the pending petition be denied. The undersigned PWCJ appropriately held Petitioner to its burden of proof on alleged medical control via its MPN and relied on substantial medical evidence in finding Lien Claimant's medical treatment was necessary and appropriate.
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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.
- 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.
- Issues, outcomes and weights were extracted by AI and released only where the source passage checked. Read the official decision before relying on anything here. Not legal advice.
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