ADJ17825300 · September 22, 2025

The WCJ found no enforceable MPN providing ancillary services, so defendant cannot assert MPN control over home care provider selection. Applicant's right to select a family member as home care provider was supported by evidence including testimony and medical authorization.

From the decision · page 1Defendant seeks reconsideration of the Findings of Fact issued on June 18, 2025, wherein the workers' compensation administrative law judge (WCJ) found as relevant that (1) while employed as a furniture salesperson on May 15, 2022, applicant sustained injury to the head, brain, and psyche, and claims to have sustained injury to the heart and sleep; (2) defendant did not meet its burden of proving that there is an approved and enforceable Medical Provider Network (MPN) that provides ancillary services; (3) there is no MPN control over the selection of the home care provider; (4) applicant has the right to select a family member as her home care provider; (5) there is a legitimate issue as to the enforceability of a MPN's control over the selection of a home care provider; (6) defendant's litigation of the issue of a MPN's control over the selection of a home care provider does not rise to the level of a bad faith action within the meaning of Labor Code section 5813; and (7) applicant is not entitled to attorney fees pursuant to Labor Code section 5813.

No enforceable Medical Provider Network providing ancillary services was established by defendant.

Favours Applicant prevailed

Without an enforceable MPN, defendant cannot assert control over home care provider selection.

From the decision · page 6Defendant's authorization does not suggest that a MPN exists which would permit it to control the provision of home care. (Ex. 4, Utilization Review Authorization Letter, April 2, 2025.) Nor does any other document in evidence. (Ex. A, Letter to Applicant's Attorney re Contacting Sedgwick Ancillary dated May 7, 2025; Opinion on Decision, p. 5; Report, p. 4.)

Favours Applicant prevailed

Supports applicant's right to select a family member as home care provider and ability of the family member to provide care.

Requested authorization for 28 hours per week of home care for six months, which defendant authorized.

Supports applicant's right to home care and selection of family member as provider.

From the decision · page 2The WCJ admitted the Primary Treating Physician's Report of Eric Yokoo, M.D., dated December 19, 2024, into evidence. (Ex. 2, Primary Treating Physician's Report of Eric Yokoo, M.D., December 19, 2024.)

Labor Code section 4600

Labor Code section 4600 requires employer to provide medical treatment reasonably required to cure or relieve injury effects.

Home health care is an appropriate benefit under section 4600, including care by family members if needed and authorized.

From the decision · page 5II. We turn first to defendant's argument that the WCJ erroneously found that it did not meet its burden of proving that there is an enforceable MPN that provides ancillary services. Specifically, defendant argues that since the parties did not frame the issue of whether an enforceable MPN exists for trial, the WCJ erred by determining the issue. Section 4600 provides that an employer must provide "[m]edical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." (§ 4600 (a).) It is well-settled that home health care is an appropriate benefit under section 4600, and that home care services need not be provided by a nursing professional to be compensable. (Henson v.

Labor Code section 5813

Labor Code section 5813 governs bad faith actions and attorney fees in workers' compensation litigation.

Defendant's litigation of MPN control issue does not rise to bad faith under section 5813; applicant not entitled to attorney fees.

From the decision · page 1Defendant seeks reconsideration of the Findings of Fact issued on June 18, 2025, wherein the workers' compensation administrative law judge (WCJ) found as relevant that (1) while employed as a furniture salesperson on May 15, 2022, applicant sustained injury to the head, brain, and psyche, and claims to have sustained injury to the heart and sleep; (2) defendant did not meet its burden of proving that there is an approved and enforceable Medical Provider Network (MPN) that provides ancillary services; (3) there is no MPN control over the selection of the home care provider; (4) applicant has the right to select a family member as her home care provider; (5) there is a legitimate issue as to the enforceability of a MPN's control over the selection of a home care provider; (6) defendant's litigation of the issue of a MPN's control over the selection of a home care provider does not rise to the level of a bad faith action within the meaning of Labor Code section 5813; and (7) applicant is not entitled to attorney fees pursuant to Labor Code section 5813.

Senate Bill 863

Senate Bill 863 provides for the use of Medical Provider Networks in workers' compensation.

Applicant's right to select family member as home care provider does not run counter to the legislative intent behind SB 863 due to lack of enforceable MPN.

From the decision · page 4As such, the issue of the defendant's ability to assert medical provider network control over the applicant's right to select her own home care provider was moot.... The defendant asserts that the Undersigned Judge's determination that the applicant has the right to select a family member as her home care provider negates the legislative goal and purpose of SB 863.... As the Undersigned Judge found no Medical Provider Network that provided ancillary services, the Undersigned Judge determined that the applicant has the right to select a family member as her home care provider, is not arbitrary and, as such, does not run counter to the legislative intent behind SB 863.