Applicant sustained a significant brain injury at work on 11/21/2022 requiring brain surgery.
Favours Applicant prevailed
This injury and ongoing symptoms justify the need for continued outpatient brain rehabilitation care.
From the decision · page 6As stated above, this Applicant sustained a brain injury on 11/21/2022 when his head struck a
metal pole resulting in subdural hematomas requiring brain surgery. He has remained under the
care of the primary treating physician, Vibhay Prasad M.D. at the Centre for Neuro Skills.
Defendants failed to show a material change in applicant's medical condition since prior authorization of ongoing rehabilitation care on July 22, 2024.
Favours Applicant prevailed
Without evidence of change, defendants cannot justify a new utilization review or termination of care.
From the decision · page 4... [T]he whole point of Patterson is that a Form RFA is not required in certain
circumstances involving care of an ongoing nature. The decision is about when
an RFA is required, and if one is not required in the first place, then there can
be no valid [utilization review] therefrom, timely or otherwise....
Defendant's argument that its allegedly timely and valid [utilization review]
determination provides substantial medical evidence of a change in
circumstances is inapplicable because the [utilization review] should never
have been issued in the first place under the reasoning in Patterson, as
explained above.
(Burton, supra, 89 Cal. Comp. Cases 977, at 980.)
As explained in the WCJ's Report, the defendants in the present case have not met their
burden of proof to show that there has been a change of circumstances since home care was found
to be reasonable and necessary on July 22, 2024. None of the exhibits admitted at expedited hearing
on March 19, 2025 provide substantial medical evidence of a significant change in applicant's
medical condition.