ADJ268422 — California WCAB decision

What the panel ordered

The WCAB grants applicant's Petition for Reconsideration and defers issuance of a final decision pending further review of the merits and the entire record.

Applicant seeks reconsideration of the September 10, 2025 Findings and Order issued by the WCJ, which denied applicant's Appeal of the IMR Final Determination and ordered further development of the record.

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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 / IMRApplicant prevailedback · shoulders · psyche

The WCJ found the IMR Final Determination was not plainly erroneous based on the evidence, but the WCAB granted reconsideration to further develop the record and review the merits due to incomplete evidence and the need for substantial evidence to support the decision.

From the decision · page 1Applicant seeks reconsideration of the September 10, 2025 Findings and Order issued by the workers' compensation administrative law judge (WCJ). Therein, the WCJ found that applicant sustained injury arising out of and in the course of employment (AOE/COE) to her back, shoulders, and psyche while employed on February 10, 2004 as a "nurse (RN)." The WCJ further found that an Findings and Award issued on July 29, 2021 finding the applicant 100% disabled; that the applicant's appeal of the IMR (Independent Medical Review) Final Determination is timely filed granting jurisdiction to the Workers' Compensation Appeals Board (WCAB); and that the applicant's appeal of the IMR Final Determination is denied in that the Determination is not based upon plainly erroneous facts. Based on these findings, the WCJ issued an order denying applicant's Appeal of the IMR Final Determination and ordering further development of the record.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Applicant's appeal of the IMR Final Determination was timely filed, granting WCAB jurisdiction to hear the matter.

Favours Applicant prevailed

This allowed the WCAB to review the IMR determination and the Petition for Reconsideration.

From the decision · page 3The issues presented in this case began with the Request for Authorization (RFA) submitted for Utilization Review (UR) by the Primary Treating Physician, Dr. Mealer on 2/15/2024. The UR issued a timely denial on 2/21/2024 and the Petitioner then filed a timely Application for Independent Medical Review (IMR) on 2/27/2024. The IMR Final Determination is dated 3/25/2024, and the Applicant's appeal is dated 6/13/2024, or approximately two and one- half months after the date of the IMR Final Determination. The WCJ found at trial that, based on the evidence, and in accordance with Labor Code Section

Applicant testified in detail about activities of daily living (ADLs) at trial, but this information was not included in the original RFA to the extent required by the Official Disability Guideline (ODG).

Favours Applicant prevailed

This affected the evaluation of the IMR Final Determination and the need for further record development.

From the decision · page 4The IMR Final Determination found a further lack of documentation in relying upon the Non-MTUS Official Disability Guideline (ODG). According to IMR, the ODG is relied on as the MTUS does not specifically address indications for home health care requests. The IMR reviewer discusses the required documentation for such requests, including the medical condition of the Applicant, the objective deficits, the tasks and services that can be performed without charge by the Applicant's spouse and other household members, the physician's treatment plan, and the need for in-home evaluations. It is noted that the Applicant did testify in some detail to these issues at trial, but that information was not included in the original RFA to the extent required by the ODG. (See Ex. BB, IMR Final Determination, attached to IMR Appeal).

Continuity of Care reports were provided to Defendant in 2020 and 2023, but no physician's RFA for home care services was sent until 2/15/2024.

Favours Defendant prevailed

This raised questions about whether Defendant failed to investigate the need for benefits, requiring further factual development.

From the decision · page 5It should be noted that some cases have held that a failure to investigate was not sufficient to render Defendant liable for the attendant/home health care assistance to the injured worker where, although evidence was provided to Defendant indicating a need for such services earlier, there were no actual physician's report with an attendant RFA for said home care services. (See Tikhonoff v. WCAB (2022) 87 CCC 419. Here, Petitioner provided the Defendant with the Continuity of Care reports on 1/30/2020 and 3/31/2023, while Dr. Mealer's report with an RFA for home health care services was sent on 2/15/2024. According to Tikhonoff, for the period prior to the RFA, there would need to be a showing of substantial evidence that the Defendant failed to investigate whether the treatment was necessary or not. The mere forwarding of the Continuity of Care reports would not satisfy that requirement. Nevertheless, more factual evidence is needed in order to determine whether there was a failure on the part of Defendant to investigate.

What proof carried it

The evidence the panel weighed, by kind.

Testimony and credibilityfavours Applicant prevailed

From the decision · page 4The IMR Final Determination found a further lack of documentation in relying upon the Non-MTUS Official Disability Guideline (ODG). According to IMR, the ODG is relied on as the MTUS does not specifically address indications for home health care requests. The IMR reviewer discusses the required documentation for such requests, including the medical condition of the Applicant, the objective deficits, the tasks and services that can be performed without charge by the Applicant's spouse and other household members, the physician's treatment plan, and the need for in-home evaluations. It is noted that the Applicant did testify in some detail to these issues at trial, but that information was not included in the original RFA to the extent required by the ODG. (See Ex. BB, IMR Final Determination, attached to IMR Appeal).

Documentary evidencefavours Defendant prevailed

Continuity of Care reports provided by applicant to defendant on 1/30/2020 and 3/31/2023, but no physician's RFA for home care services until 2/15/2024.

From the decision · page 5It should be noted that some cases have held that a failure to investigate was not sufficient to render Defendant liable for the attendant/home health care assistance to the injured worker where, although evidence was provided to Defendant indicating a need for such services earlier, there were no actual physician's report with an attendant RFA for said home care services. (See Tikhonoff v. WCAB (2022) 87 CCC 419. Here, Petitioner provided the Defendant with the Continuity of Care reports on 1/30/2020 and 3/31/2023, while Dr. Mealer's report with an RFA for home health care services was sent on 2/15/2024. According to Tikhonoff, for the period prior to the RFA, there would need to be a showing of substantial evidence that the Defendant failed to investigate whether the treatment was necessary or not. The mere forwarding of the Continuity of Care reports would not satisfy that requirement. Nevertheless, more factual evidence is needed in order to determine whether there was a failure on the part of Defendant to investigate.

ADJ268422 · January 5, 2026

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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The rules the panel named

What proof carried it

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