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PanelQMEDenied

Ramirez, Mario

MARIO RAMIREZ, Applicant vs. ESG PERSONNEL LEASING, INC., LSC LARSEN’S OXNARD GRILL; SECURITY NATIONAL INSURANCE COMPANY, administered by AMTRUST NORTH AMERICA, Defendants

ADJ number: ADJ15193432
Decision date: Sep 1, 2025
District office: Santa Barbara
WCJ: —
Claim administrator: AmTrust North America (administering for Security National Insurance Company)
Commissioners: KATHERINE WILLIAMS DODD, COMMISSIONER, KATHERINE A. ZALEWSKI, CHAIR, JOSEPH V. CAPURRO, COMMISSIONER

Injury / body parts: low back, lumbar spine

LC §4604LC §4610LC §5700LC §5701LC §5900LC §5909CCR §9792.9.1CCR §9792.21.1CCR §10600

Summary

Applicant Mario Ramirez sustained an industrial low back injury on June 30, 2021 while working as a cook/restaurant worker, ultimately undergoing four lumbar surgeries. After a March 26, 2025 UR denial of an SCS trial (for lack of psychiatric clearance) and an April 17, 2025 UR denial (for failure to exhaust conservative care/repeat ESI), the PTP submitted a new RFA on May 5, 2025 marked 'Resubmission – Change in Material Facts,' supported by an April 29, 2025 report noting the April 7, 2025 repeat ESI provided no lasting relief and that psychological clearance was completed. Defendant declined to submit the new RFA to UR, invoking the 12-month rule under section 4610(k). The WCJ found the May 7, 2025 UR denial invalid/untimely and the SCS trial medically necessary, and the Appeals Board denied defendant's petition for reconsideration, holding that a documented change in material facts obligated defendant to either authorize the treatment or refer it to UR.

Issues

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Holding

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Analysis

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Applicant takeaway

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Defense takeaway

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Provider takeaway

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Similar decisions

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Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.

Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.

Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.

Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.

Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.

Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.

Full case search with summaries, PDFs, holdings, and filters is included with Member. This block is a decorative placeholder so the page layout is visible without exposing restricted text. Sign in or subscribe to Member to read the complete decision. 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.