PanelQMEDenied
Chantel Sevillano — ADJ11380052
CHANTEL SEVILLANO, Applicant vs. KORE 1 INC.; ATLANTIC SPECIALTY INSURANCE COMPANY, adjusted by INTACT INSURANCE SPECIALTY SOLUTIONS, Defendants
- ADJ number
- ADJ11380052
- Decision date
- Jul 17, 2022
- District office
- Van Nuys
- WCJ
- —
- Claim administrator
- Intact Insurance Specialty Solutions (adjusting for Atlantic Specialty Insurance Company)
- Commissioners
- KATHERINE A. ZALEWSKI, CHAIR, MARGUERITE SWEENEY, COMMISSIONER, JOSÉ H. RAZO, COMMISSIONER
Injury / body parts: head, neck, upper back, brain, eyes, right shoulder, psyche, nausea, headaches, insomnia
LC §4600LC §4610LC §4622LC §5903LC §5905LC §5906CCR §9792.9.1CCR §10109CCR §10848CCR §10964
Summary
Applicant, a scheduling clerk, sustained an industrial injury on June 1, 2018 when struck in the head by a tree branch, with accepted injury to head, neck, and upper back and claimed injuries to additional parts. The PTP, Dr. Chodakiewitz, requested an outpatient rehabilitation program for balance and pain management. Defendant's attorney received the November 17, 2021 PTP report labeled 'Request for Authorization' on November 22, 2021 but did not submit it for UR until approximately February 14, 2022, with a modified denial issued February 21, 2022. The WCJ found the UR untimely, giving the WCAB jurisdiction under Dubon to decide medical necessity, and found substantial evidence supported the treatment. The Board denied reconsideration, holding the November 17 report met the requirements of CCR 9792.9.1(c)(2)(B), the defense failed in its duty to investigate and timely transmit the request for UR, and the treatment was supported by substantial medical evidence.
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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