Ronnie Marciel, vs. Atwater Elementary School District; Permissibly Self-insured; Adjusted By Schools Insurance Authority,

(STK 0211347)In this case, Ronnie Marciel, an employee of Atwater Elementary School District, sought reconsideration of a Workers' Compensation Administrative Law Judge's decision to deny his appeal of an Independent Medical Review (IMR) Determination. The IMR Determination denied the use of fluoroscopy for a trigger point injection that had been approved through utilization review (UR). The Workers' Compensation Appeals Board granted reconsideration and rescinded the WCJ's order, returning the matter to allow applicant to obtain a new IMR determination. The Board found that the IMR determination was erroneous as it exceeded the scope of its review by finding that all of the treatment, even the treatment approved by UR, was medically unnecessary.

Atwater Elementary School District; Permissibly Self-Insured; adjusted by Schools Insurance Authority, Ronnie Marciel, WORKERS’ COMPENSATION APPEALS BOARDSTATE OF CALIFORNIARONNIE MARCIEL,Applicant,vs.ATWATER ELEMENTARY SCHOOL DISTRICT; Permissibly Self-Insured; adjusted by SCHOOLS INSURANCE AUTHORITY,Defendants.Case No. ADJ4282886 (STK 0211347)OPINION AND DECISION AFTER RECONSIDERATION            We granted reconsideration in this matter to provide an opportunity to further study the legal and factual issues raised by the petition for reconsideration. Having completed our review, we now issue our Decision After Reconsideration.            Applicant, Ronnie Marciel, seeks reconsideration of the Findings and Order, issued October 17, 2016, in which a workers’ compensation administrative law judge (WCJ) denied applicant’s appeal of the November 16, 2015 Administrative Director’s Independent Medical Review (IMR) Determination, finding applicant failed to show that the determination has been rebutted by clear and convincing evidence.            Applicant contends the IMR determination was an act without or in excess of the Administrative Director’s powers, and was the result of a plainly erroneous express or implied finding of fact not subject to expert opinion, as the IMR reviewer did not address the medical issue presented for review, whether fluoroscopy was an appropriate procedure to perform a trigger point injection, which had been approved through utilization review (UR), but modified to exclude the use of fluoroscopy. Instead, the IMR reviewer addressed whether applicant was in need of a trigger point injection with fluoroscopy, finding the trigger point injection was not medically necessary, and therefore finding fluoroscopy was not necessary. Applicant argues that because the IMR reviewer was not authorized to review whether applicant was in need of the trigger point injection, the reviewer lacked a basis to deny the use of , fluoroscopy.            No Answ

To continue reading ... start a FREE Trial for 10 days

Discover the cases you didn’t know you were missing!

Copyright © 2023 - CompFox Inc.