Rodriguez, Orlando

Orlando Rodriguez, a mechanic/diesel engineer, sustained a traumatic brain injury with multiple skull fractures on November 11, 2016, requiring a decompressive craniectomy and ongoing home health aide services (12 hours/day, 7 days/week) that defendant voluntarily authorized beginning September 2018. After UR certified the home health services as medically necessary in May and August 2019, defendant's UR non-certified continued services on September 19, 2019. The WCJ found applicant had a continual, ongoing need for home health care since September 27, 2018, that no material change in condition had been shown, and that the September 19, 2019 UR was therefore moot. Applying Patterson, the Appeals Board held that once treatment is authorized as medically necessary, defendant bears the burden of proving a material change in condition or circumstance before unilaterally terminating care and cannot shift that burden by demanding a new RFA and starting UR over. Finding defendant failed to prove a material change, the Board affirmed the F&O.