Cruz, Victor

Applicant Victor Cruz sustained a head injury/mild traumatic brain injury and received post-acute neurorehabilitation treatment at the Centre for Neuro Skills (CNS), which defendant authorized multiple times through utilization review (UR). When defendant later issued a timely UR denial of a renewed RFA for the same level of treatment (4 hours/day, 5 days/week), applicant pursued an Expedited Hearing rather than IMR, arguing the WCJ retained jurisdiction under Patterson v. The Oaks Farm. The WCJ found applicant required continuing treatment because defendant failed to present substantial medical evidence of a change in condition or circumstances justifying discontinuation. The WCAB denied defendant's Petition for Reconsideration, adopting the WCJ's Report, holding that under Patterson defendant bore the burden of proving a material change in condition and that its UR/peer-review evidence was conclusory and insufficient. The Board also rejected defendant's reliance on Allied Signal/Wiggs and confirmed QMEs cannot opine on treatment disputes.