Injury / body parts: lumbar spine, left shoulder, left wrist, left knee, psyche
CCR §9792.5.5CCR §9792
Summary
Darryl Shelmire sustained industrial injuries on June 8, 2012 while working as a mortgage loan consultant for Kinecta Federal Credit Union to his lumbar spine, left shoulder, left wrist, left knee, and psyche. On May 18, 2023, the WCJ awarded reimbursement of the lien of treating physician Edwin Haronian, M.D. The defendant petitioned for reconsideration, arguing that the lien claimant's failure to request second bill review (SBR) under CCR 9792.5.5 in response to defendant's explanations of review (EOBs) required that the bills be deemed satisfied. The WCAB denied reconsideration, adopting the WCJ's reasoning that EOBs disallowing charges based on lack of medical necessity (allowing 'zero' payment) do not trigger the SBR requirement because no 'amount of payment' was actually disputed, and that defendants cannot use the EOB process to re-litigate the reasonableness/necessity of treatment after authorizing it or failing to contest it through UR.
Issues
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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Holding
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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Analysis
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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Applicant takeaway
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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Defense takeaway
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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Provider takeaway
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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Similar decisions
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
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The panel considered the record, the applicable statutes, and the arguments of the parties.
Member is $25/month or $250/year and includes the weekly email digest, full case search, and bookmarks.