ADJ15692843 — California WCAB decision

What the panel ordered

Petition for Reconsideration granted; Findings and Award issued September 26, 2023 rescinded; matter returned to trial level for further proceedings.

Petition for Reconsideration filed by defendant seeking review of Findings and Award issued September 26, 2023, regarding medical necessity of home health care; WCJ issued Report and Recommendation to deny petition; Board granted reconsideration and rescinded F&A, returning matter for further proceedings.

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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.

Medical treatment / UR / IMRRemandedactivities of daily living

The Board found that the WCJ's award of home health care was not supported by sufficient explanation of how the applicant's symptomatology met the criteria for home health care under the MTUS, and the type and duration of services were not specified, warranting further development of the record.

From the decision · page 7Here, the record shows that Dr. Merman concluded that applicant requires home health care of four hours per day, five days per week, but his reporting does not explain how applicant's symptomology met criteria applicable for that determination. (Ex. AA, PTP PR-2 and RFA from Jan Merman, M.D., March 16, 2023, pp. 2-4; Ex. CC, PTP PR-2 and RFA from Jan Merman, M.D., April 17, 2023, pp. 27-29.)

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.

PTPRejected

Concluded applicant requires home health care four hours per day, five days per week, but did not explain how symptomatology met criteria or specify type and duration of services.

From the decision · page 7Here, the record shows that Dr. Merman concluded that applicant requires home health care of four hours per day, five days per week, but his reporting does not explain how applicant's symptomology met criteria applicable for that determination. (Ex. AA, PTP PR-2 and RFA from Jan Merman, M.D., March 16, 2023, pp. 2-4; Ex. CC, PTP PR-2 and RFA from Jan Merman, M.D., April 17, 2023, pp. 27-29.)

otherNot substantial evidence · neurology

Diagnosed daily new persistent headache and treated with Elavil; noted prior infrequent headaches and brain MRI findings.

From the decision · page 3The patient saw Dr. Teresa Luna, neurologist, on April 8, 2021. However, he told her prior to COVID, he had no headaches or at least sporadic and infrequent. His headaches were 20 to 25 days a month when he saw Dr. Luna mild-to-moderate. She diagnosed him with daily new persistent headache and started him on Elavil. She wanted to get an MRI scan of his brain which was done on August 19, 2021 which revealed numerous nonspecific punctate T2 hyperintense lesions with subcortical deep white matter which could represent demyelinating diseases versus vasculitis versus migraine headaches versus chronic microvascular ischemic changes.... After review of the records, there are some discrepancies. For instance, he told Dr. Luna that he has no headaches or occasional headaches. However, previous headaches are more frequent prior to COVID infection. He also had multiple areas of stress which included work-related stress probably from overworking 15 to 16 hours a day. However, he also had problems with his wife. He also had back injury possibly a knee injury from his employment, which could have cause stress.

ADJ15692843 · December 12, 2023

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

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