ADJ9091752 — California WCAB decision

What the panel ordered

Findings and Order issued by WCJ on 02/27/2020 disallowing Dental Trauma Center's lien affirmed

Petition for Reconsideration granted to study lien claimant's issues, then denied after review

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.

LiensDefendant prevailedteeth · dental system

The lien claimant failed to prove that the dental treatment was reasonably required to cure or relieve the applicant from the effects of the industrial injury, and the medical reports lacked substantial evidence and reasoning to support the lien claim.

From the decision · page 4Here, the report from qualified medical examiner John L. Howard, M.D., submitted by DTC as exhibit 7, states that applicant was "post cervical strain" and "post lumbar strain", and the doctor stated that, "Future medical treatment is not required." (L.C. Exh. 7, Dr. Howard, October 7, 2015, pp. 9 § 10.) Dr. Howard also noted that applicant had been released from care by treating physician Dr. Michael Moheimani, in July 2015. (L.C. Exh. 7, p. 3.) Dr. Schames did not explain why after being released from care, that applicant needed further treatment. Nor did Dr. Schames explain why, that even though applicant had not claimed injury to his teeth or dental system, the dental treatment Dr. Schames provided was reasonably required to cure or relieve applicant from the effects of applicant's industrial injury. (Lab. Code, § 4600(a).) A medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (Zemke v.

The facts that decided it

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

Dr. John L. Howard's QME report stated no future medical treatment was required and applicant was released from care in July 2015

Favours Defendant prevailed

Supports disallowance of lien for dental treatment as no further treatment was reasonably required

From the decision · page 4Here, the report from qualified medical examiner John L. Howard, M.D., submitted by DTC as exhibit 7, states that applicant was "post cervical strain" and "post lumbar strain", and the doctor stated that, "Future medical treatment is not required." (L.C. Exh. 7, Dr. Howard, October 7, 2015, pp. 9 § 10.) Dr. Howard also noted that applicant had been released from care by treating physician Dr. Michael Moheimani, in July 2015. (L.C. Exh. 7, p. 3.) Dr. Schames did not explain why after being released from care, that applicant needed further treatment. Nor did Dr. Schames explain why, that even though applicant had not claimed injury to his teeth or dental system, the dental treatment Dr. Schames provided was reasonably required to cure or relieve applicant from the effects of applicant's industrial injury. (Lab. Code, § 4600(a).) A medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (Zemke v.

Dr. Mayer Schames did not explain why dental treatment was reasonably required or why applicant needed further treatment after release from care

Favours Defendant prevailed

Reports lacked substantial evidence and reasoning to support lien claim, leading to disallowance

From the decision · page 4Here, the report from qualified medical examiner John L. Howard, M.D., submitted by DTC as exhibit 7, states that applicant was "post cervical strain" and "post lumbar strain", and the doctor stated that, "Future medical treatment is not required." (L.C. Exh. 7, Dr. Howard, October 7, 2015, pp. 9 § 10.) Dr. Howard also noted that applicant had been released from care by treating physician Dr. Michael Moheimani, in July 2015. (L.C. Exh. 7, p. 3.) Dr. Schames did not explain why after being released from care, that applicant needed further treatment. Nor did Dr. Schames explain why, that even though applicant had not claimed injury to his teeth or dental system, the dental treatment Dr. Schames provided was reasonably required to cure or relieve applicant from the effects of applicant's industrial injury. (Lab. Code, § 4600(a).) A medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (Zemke v.

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.

QMERelied upon

Applicant was post cervical and lumbar strain; future medical treatment not required; released from care by treating physician in July 2015.

Report states no future medical treatment required and applicant was released from care; supports disallowance of lien for dental treatment.

From the decision · page 4Here, the report from qualified medical examiner John L. Howard, M.D., submitted by DTC as exhibit 7, states that applicant was "post cervical strain" and "post lumbar strain", and the doctor stated that, "Future medical treatment is not required." (L.C. Exh. 7, Dr. Howard, October 7, 2015, pp. 9 § 10.) Dr. Howard also noted that applicant had been released from care by treating physician Dr. Michael Moheimani, in July 2015. (L.C. Exh. 7, p. 3.) Dr. Schames did not explain why after being released from care, that applicant needed further treatment. Nor did Dr. Schames explain why, that even though applicant had not claimed injury to his teeth or dental system, the dental treatment Dr. Schames provided was reasonably required to cure or relieve applicant from the effects of applicant's industrial injury. (Lab. Code, § 4600(a).) A medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (Zemke v.

PTPRelied upon

Applicant released from care in July 2015.

Supports that no further treatment was reasonably required.

From the decision · page 4Here, the report from qualified medical examiner John L. Howard, M.D., submitted by DTC as exhibit 7, states that applicant was "post cervical strain" and "post lumbar strain", and the doctor stated that, "Future medical treatment is not required." (L.C. Exh. 7, Dr. Howard, October 7, 2015, pp. 9 § 10.) Dr. Howard also noted that applicant had been released from care by treating physician Dr. Michael Moheimani, in July 2015. (L.C. Exh. 7, p. 3.) Dr. Schames did not explain why after being released from care, that applicant needed further treatment. Nor did Dr. Schames explain why, that even though applicant had not claimed injury to his teeth or dental system, the dental treatment Dr. Schames provided was reasonably required to cure or relieve applicant from the effects of applicant's industrial injury. (Lab. Code, § 4600(a).) A medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (Zemke v.

otherRejected · dentist

Did not explain why dental treatment was reasonably required or why applicant needed further treatment after release from care; reports not substantial evidence.

Reports lacked explanation and reasoning to support that dental treatment was reasonably required for industrial injury; thus not substantial evidence.

From the decision · page 4Here, the report from qualified medical examiner John L. Howard, M.D., submitted by DTC as exhibit 7, states that applicant was "post cervical strain" and "post lumbar strain", and the doctor stated that, "Future medical treatment is not required." (L.C. Exh. 7, Dr. Howard, October 7, 2015, pp. 9 § 10.) Dr. Howard also noted that applicant had been released from care by treating physician Dr. Michael Moheimani, in July 2015. (L.C. Exh. 7, p. 3.) Dr. Schames did not explain why after being released from care, that applicant needed further treatment. Nor did Dr. Schames explain why, that even though applicant had not claimed injury to his teeth or dental system, the dental treatment Dr. Schames provided was reasonably required to cure or relieve applicant from the effects of applicant's industrial injury. (Lab. Code, § 4600(a).) A medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (Zemke v.

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code section 4600(a)

Burden of proof rests on lien claimant to show treatment was reasonably required to cure or relieve effects of industrial injury

Applied to deny lien claim due to lack of substantial evidence that dental treatment was reasonably required

From the decision · page 4burden of proof includes the burden of showing that he or she provided medical treatment "reasonably required to cure or relieve" the injured worker from the effects of an industrial injury. (Lab. Code, § 4600(a); Williams v. Industrial Acc. Com. (1966) 64 Cal.2d 618 [31 Cal.Comp.Cases 186]; Beverly Hills Multispecialty Group, Inc. v. Workers' Comp. Appeals Bd. (1994) 26 Cal.App.4th 789 [59 Cal.Comp.Cases 461].)

Labor Code section 5705

Burden of proof rests upon party holding affirmative of issue

Applied to lien claimant to prove lien claim

From the decision · page 3(In re: COVID-19 State of Emergency En Banc (2020) 85 Cal.Comp.Cases 296 (Appeals Board en banc).) The district offices reopened for filing on April 13, 2020. Therefore, the filing deadline for a petition for reconsideration that would have occurred during the district offices' closure was tolled until April 13, 2020, and the Petition was timely filed. Therefore, the Petition is deemed filed on April 13, 2020, and the opinion granting the Petition issued within the 60-day period. Having reviewed the trial record, as well as the Electronic Adjudication Management System (EAMS) ADJ file, we agree with the WCJ's analysis and reasoning for reaching his conclusions as stated in the F&O, and his explanation of those conclusions as stated in the Report. Notwithstanding the fact that we agree with the WCJ disallowing DTC's lien, for the purpose of clarity, we will address DTC's argument that its lien should be, "...decided on the merits of the case, not on alleged procedural defects" (Petition pp. 4 § 5.). We first note that pursuant to Labor Code section 5705, "The burden of proof rests upon the party or lien claimant holding the affirmative of the issue." (Lab. Code, § 5705.) A lien claimant treating physician's

Zemke v. Workmen's Comp. Appeals Bd. (1968) 68 Cal.2d 794

Medical report must set forth reasoning behind physician's opinion to be substantial evidence

Applied to reject Dr. Schames' reports as not substantial evidence

From the decision · page 4Workmen's Comp. Appeals Bd. (1968) 68 Cal.2d 794 [33 Cal.Comp.Cases 358]; Granado v. Workers' Comp. Appeals Bd. (1968) 69 Cal.2d 399, 407 [33 Cal.Comp.Cases 647].) Thus, Dr. Schames' reports are not substantial evidence and in turn, would not be an appropriate basis for awarding payment of DTC's lien. (Lab. Code, § 5952(d); Lamb v. Workmen's Comp. Appeals Bd. (1974) 11 Cal.3d 274, 281 [39 Cal.Comp.Cases 310]; Garza v. Workmen's Comp. Appeals Bd. (1970) 3 Cal.3d 312, 317 [35 Cal.Comp.Cases 500].) Again, as noted by the WCJ, all other issues, "are moot in light of the foregoing." (F&O, p. 2.)

ADJ9091752 · October 26, 2022

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

What the panel did with the medical opinions

The rules the panel named

What proof carried it

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