California Work Comp News, Issues,
Articles Daily - min. 3 posts Daily
September 30, 2014: New 10 IMR Decisions Posted 1
Reversed - Rest upheld based on Incomplete RFAs


September 29, 2014: New IBR Decisions Posted: All
Three Allowed Additional Monies for Provider

-63047  /63048
-22/830 /22855 / 63090 / 63091
-82145 /82205 / 80154 / 82520 / 83480 / 83992 / 83925
/ 83925 59 / 82145 59 / 82055 / 82057

September 29, 2014: IMR Pain Management  and
Psychiatric Treatment

September 25, 2014: MRI What some MRI Requests are
missing and being upheld on IMRs - Documentation
highly template – difficult to follow

September 25, 2014: Case Law: ***
As guidance to the parties, however, we note that under
Administrative Director Rule  9792.6.1(b), requests for
treatment authorization after July 1, 2013 must be
accompanied by "a  completed 'Request for Authorization
for Medical Treatment,' DWC Form RFA [...] that has
been transmitted by the treating physician to the claims
administrator."

September 25, 2014: Article:
Are The majority of UR denials defective based on some
insurance companies generic forms in issuing UR denials

September 25, 2014: Case Law:
Although timely, the failure to provide all of the relevant
reports and information in defendant's possession is
grounds to find UR to be procedurally deficient and the
treatment issue may be determined at an Expedited
Hearing before completion of Labor Code §4062
 

September 25, 2014: Case Law:
If the employee elects not to file a timely request for
IMR, the employee does so at his or her peril, i.e., the
employee might have no remedy if the WCAB finds the
employer's UR decision was timely and procedurally
valid" (slip opn., 10 page 14). Therefore, we find that
applicant did not waive his right to WCAB determination
of whether  defendant's UR decision was timely and valid.

September 24, 2014: Toxicology the simplest of services
to get authorized and providers are missing it
CALIFORNIA WORKERS COMPENSATION COLLECTIONS PUBLICATIONS AND
INFORMATION FOR MEDICAL PROVIDERS AND LIEN CLAIMANTS
All States Work Comp News,
Issues, Articles Daily
September 25, 2014 Oregon News:
Hospital fee schedule – adjusted cost-to-
charge ratios for Oregon hospitals

September 24, 2014: Illinois News:
2015 Fee schedule rates will increase
1.70%

Medical fee schedule rates will increase
1.70% on January 1, 2015. The 2015
rates will be 38% lower than medical
inflation since the fee schedule took
effect in 2006.

September 24, 2014: Idaho News:
30% Penalty on Medical Fee Disputes

September 24, 2014: Arkansas Case Law:
Even though Dr. Sites indicated that this
injury occurred at work as well, claimant
has not filed a claim for any injury having
occurred some six months prior to
October 29, 2013, and a finding that the
August 1, 2013 date is the injury referred
to by Dr. Sites as having occurred six
months prior to October 29, 2013, would
require speculation and conjecture

September 16, 2014: Idaho Case Law:
A motion for reconsideration must
“present to the Commission new reasons
factually and legally to support
[reconsideration] rather than rehashing
evidence previously presented.” Curtis v.
M.H. King Co., 142 Idaho 383, 128 P.3d
920 (2005). The Commission is not
inclined to reweigh evidence and
arguments simply because the case was
not resolved in the party’s favor.

September 16, 2014: Colorado News:
Colorado Division of Workers’
Compensation
2014 Legislative Advisory
Panel Decision:
The fact that the record does not contain an express designation
of Dr. Mays as the primary treating physician should not defeat a
legitimate claim for medical treatment services.

Panel Decision in line with En Banc Simmons: Proper
mechanism for objecting to medical determinations by a primary
treating physician where liability to at least one body part has been
accepted.

Panel Decision:
Letter correctly addressed and properly mailed is
23 presumed to have been received in the ordinary course of mail
(Evid. Code, § 641).
Panel Decision:
We find that sanctions are warranted in this case in that the
language used by applicant's counsel in the Petition for
Reconsideration is insulting, offensive, insolent, intemperate and
disrespectful towards the WCJ.
Recent En Banc Decision on QME Process

Panel Decision:
"...when the Order Dismissing had been served on lien
claimant. It was therefore not clear whether the
Petition was timely filed." (Report, pp. 1-2.)

Panel Decision:
Kunz and Tapia cases really focus on evidence of what the
lien claimant usually accepts

Panel Decision:
"Here, we conclude that the defendant's UR process suffers
from material procedural defects that undermine the integrity
of the UR decision because the UR physicians were not
provided with adequate medical records."
Panel Decision:
sanctions: litigating a lien to the point of setting it for
trial without submitting any evidence in support thereof
Recent En Banc Decision on QME Process

Panel Decision:
"...when the Order Dismissing had been served on lien
claimant. It was therefore not clear whether the
Petition was timely filed." (Report, pp. 1-2.)

Panel Decision:
Kunz and Tapia cases really focus on evidence of what the
lien claimant usually accepts

Panel Decision:
"Here, we conclude that the defendant's UR process suffers
from material procedural defects that undermine the integrity
of the UR decision because the UR physicians were not
provided with adequate medical records."

Panel Decision:
sanctions: litigating a lien to the point of setting it for
trial without submitting any evidence in support thereof
Panel Decision:
"Compensable consequences" doctrine. Under this doctrine,
where a subsequent injury is the consequence of an original
industrial  injury, the subsequent injury is considered to relate
back to the original injury

F Panel Decision:
Appeals Board States When SCIF can use Blue Cross PPO discount
WCAB Published Significant Panel Decision: An expedited
hearing may be requested and conducted under Labor Code section
5502(b)(2) and Administrative Director Rule 9767.6(c) to
determine whether the employee must treat in the employer’s
medical provider network during the 90-day delay

Panel Decision:
Here, applicant's attorney barely manages to squeeze the petition
for reconsideration into 25 pages, but he does so only by
violating the 12-point font size requirement (§§ 10845(a),
10205.12(a)(5) [formerly, § 10232(a)(5)1) and possibly by
violating the line- spacing requirement as well (§§ 10845(a),
10205.12(a)(11) [formerly, § 10232(a)(1 1)]).
Panel Decision:
Lien claimant did not file the Petition for Reconsideration within
25 days of the decision (20 days per Labor Code section 5903,
plus 5 days for mailing per Code of Civil Procedure section 1013).
Panel Decision:
The WCJ's determination "must be based on admitted evidence in
the record."

Labor Code section 5313 requires the WCJ to "make and file
findings upon all facts involved in the controversy

Panel Decision:
“It appears that lien claimant does not fully  understand its
evidentiary burden. Under Labor Code section 5705, "The burden
of proof rests upon the party or lien claimant holding the
affirmative of the issue."
Panel Decision:
"...we strongly admonish applicant's counsel for citing medical
reports that are not in evidence, thereby failing to "fairly state
all of the material evidence relative to the point or points at issue
[,]"
Panel Decision
Order of Dismissal Lien Served by Defense and not Board Held
Invalid Order for Dismissal.
Panel Decision:
Sanctions for Lien Claimant withdrawing DOR
Panel Decision:
"Finally, we note that Labor code section 4907 will be expanded
on January 01, 2013. Beginning on that date, a Lien
Representative may lose the privilege of practicing before the
WCAB..."
: Panel Decision:
Lien claimants offered no evidence of the OMFS for the
services provided to treat applicant's industrial injury.
Panel Decision: Evidence:
However, while a party's failure to lay a foundation, to
authenticate, and to corroborate documentary evidence with
oral testimony may affect the weight and substantiality of the
evidence, these possible deficiencies do not necessarily render
that evidence inadmissible.

Panel Decision:
Additionally, even if lien claimant's assertion about lack of
notice were correct, lien claimant's skeletal petition for
reconsideration would still be "unsupported by specific
references to the record and to the principles of law involved"
and thus subject to dismissal. (Cal. Code Regs., tit. 8, § 10846.)
Panel Decision:
"... the petition fails to identify what "good cause" petitioners
contend supports rescission of the WCJ's Order. The petitions
are also unverified."
Panel Decision:
Moreover, although the presumption of proper mail service
may be rebutted by evidence that the Findings and Order was
not in fact mailed as declared by the proof of service  a bare
declaration of non-receipt is insufficient to overcome proof
of service.g
Panel Decision:
Sanctions-- Lien claimant for failure to respond to NOI
: Panel Decision:
Labor Code section 5502(b) establishes issues which require
expedited hearing. As of 2012,these issues did not include MPN
issues or issues regarding attorney's fees. However, because the case
is now off calendar, defendant's Petition for Removal is moot, and
we deny it.

Panel Decision:
"With regard to the defendant's contention that the lien claimant's
attorney did not state under penalty of perjury that the attorney
was appearing on no other matters on that date and that the entire
time was spent at the Pomona Board exclusively waiting for the
defendant to appear in this matter,
the defendant cites no legal authority that in order for the court to
award costs that said Petition must include such a declaration."

Panel Decision:
“…affirmative burden of proving all of the elements  necessary to
establishment of its lien and all relevant issues, including that the
lien was for properly  provided services and that the claim is
industrially related.”  “…also require that lien claimant prove that
the treatment rendered was reasonable and necessary to cure or
relieve the effects of the injury.”

Panel Decision:
“…defendant unreasonably delayed applicant's referral to his
treating spinal surgeon for a surgical consultation and unreasonably
delayed provision of spinal surgery.”
Panel Decision:
However, we note that, although lien claimant filed a Request to be
Available by Phone for the November 21, 2012 lien conference,
there is no indication in the record that the WCJ granted that
request. Notifying an opposing party, or even the WCAB, of
unavailability does not in itself excuse  failure to appear.

Panel Decision:
The verified petition for reconsideration is impermissibly skeletal,
contrary to California Code of Regulations, title 8, section 10846.
It is unsupported by specific references to the record and to the
principles of law involved.
Panel Decision:
"In order to have been "prior timely payments," the payments
would have had to be made prior to 8:30 a.m. on the date of the
lien conference"
Panel Decision:
Lien claimant's excuse for failing to obtain permission and for
filing duplicate documents is that it assumed that the documents  
would be discarded, and it contends that it was not aware of a
provision that would impose sanctions for that behavior.

Panel Decision:
However, we determine that lien claimant may have
misunderstood the language and effect of the Order quoted
above. As such, lien claimant may have been objecting to the
Notice and seeking reconsideration if the Order of Dismissal was
in effect
.

Panel Decision:
Pre-trial orders regarding evidence, discovery, trial setting,
venue, or similar issues - such as the orders here - are non-final
interlocutory orders that do not determine any substantive right
of the parties. Accordingly, the Petition, to the extent it seeks
reconsideration, must be dismissed
New En Banc Decision:
Mercy is an “air carrier that may provide air transportation”
within the meaning of the preemption provision of the ADA.?

Panel Decision:
Lien claimant's excuse for failing to obtain permission and for
filing duplicate documents

Panel Decision:
However, we determine that lien claimant may have
misunderstood the language and effect of the Order

Panel Decision:
Pre-trial orders regarding evidence, discovery, trial setting,
venue, or similar issues -
Panel Decision:
Appeals agrees with Lien Claimant there was no intention to
cause unreasonable or unnecessary delay, and not motivated by
bad faith reduce sanctions from$2,500.0 to $500.00 still
unnecessary hearing.

Panel Decision:
The Court does not believe relief should be granted per CCP
473.If the WCAB does determine that relief should be granted,
as CCP 473 includes mandatory costs and sanctions, the
matter should be returned to the trial level for the award of
same.
Panel Decision:
Treatment outside MPN allowed whenLack of Notice that
results in a neglect or refusal to provide reasonable medical
treatment renders the employer or insurer liable for
reasonable medical treatment self-procured by the
employee." (71 Cal.Comp.Cases at1435.)

Panel Decision:
Notice of Intent not a final Order and not subject to Petition
for Reconsideration unless order served by Court

Panel Decision:
There are no citations to any evidence or actual testimony,
as required by WCABRule 10842.

Panel Decision:
The supplemental response shall only address evidence and
issues raised in lien claimant's Answer, and shall not address
any other evidence or raise any other issues, and must befiled
within fifteen (15) days, plus an additional five (5) days for
mailing
Panel Decision:
Treatment outside MPN allowed when Lack of Notice that
results in a neglect or refusal to provide reasonable
En Banc Decision:
Where a medical-legal lien claim for copy costs was filed
before January 1, 2013, and after January 1, 2013 it was
withdrawn and re-filed as a petition for costs under Labor
Code section 5811, the Appeals Board held:
Panel Decision:
A failure to fairly state all of the material evidence may be a
basis for denying the petition." (Cal. Code Regs., tit. 8, § 10842.

Panel Decision
Lien Claimant ordered to pay $10,030.25 in cost and sanctions

Panel Decision: NOI:
A letter that is properly addressed and mailed is presumed to be
received, and a bare statement of non-receipt is insufficient to
overcome proof of service. . Additionally, even if lien
claimant's assertion about lack of notice were correct, lien
claimant's skeletal petition for reconsideration would still be
"unsupported by specific references to the record and to the
principles of law involved" and thus subject to dismissal. (Cal.
Code Regs., tit. 8, § 10846.)

Panel Decision MPN Issue:
The record reflects a neglect or refusal to provide reasonable
medical treatment because defendant did not carry its burden of
proving that such treatment was properly available to applicant
through its MPN. For that reason, defendant is liable for the
cost of the reasonable medical treatment self-procured by
applicant.
Panel Decision:
As discussed above, section 4600(a) imposes a mandatory duty
to timely provide reasonably required medical treatment. The
Labor Code does not permit a defendant to bury its head in the
sand in order to dodge its obligations.

Panel Decision:
A medical provider lien claimant can no longer present a
prima facie case merely by demonstrating that the treatment
giving rise to the lien claim was for an alleged
industrial injury. To the contrary, the present rule of law is
that Lien Claimants have the burden of proof on their lien
claims, including the burden to demonstrate every
element necessary for recovery unless that element was
previously adjudicated or admitted by the employer.
Panel Decision:
It is also recommended that petitioner be admonished not to file
Petitions for Reconsideration and mislabel them as
Objection-other and to comply with Reg. 10842.
Panel Decision:
The language of the statute is mandatory concerning the
payment of an activation fee by the lien claimant at the lien
conference, and the sanction of dismissal of the lien with
prejudice should the lien claimant fail to pay the fee or show
proof of such payment at the lien conference.

Panel Decision:
“____________ have violated a number of important WCAB
Rules in the underlying proceedings and in the Petition for
Reconsideration, making the imposition of Labor Code section
5813 sanctions appropriate in this case.”
Panel Decision:
as CCP 473 includes mandatory costs and sanctions, the matter
should be returned to the trial level for the award of same.

Panel Decision:
Defendants allege that the Qualified Medical Examiner should
not have his charges adjudicated in the absence of a lien.
Panel Decision:
but none of the evidence submitted is evidence that applicant
received notice or that lien
claimants received notice.
WCAB Post En Banc Decision:
Bengals are exempted by section 3600.5(b) from the provisions
of California’s workers’ compensation law,

Panel Decision:
Lien Claimant contends it was error to dismiss its lien solely for
failure to pay the lien activation fee which it described as a
technicality. This contention is frivolous in light of the express
language of Labor Code section 5903.06 (a) (1), (a) 2 and (a)
(4).
Panel Decision:
Additionally, it is unclear why lien claimants have raised Code
of Civil Procedure section 473.Claims of mistake, inadvertence,
surprise, or excusable neglect under Code of Civil Procedure
section 473 cannot be used as a basis for avoiding dismissal.

Panel Decision:
Labor Code section 4620 defines "medical-legal expenses" as
any costs and expenses incurred by or on behalf of any party for
X-rays, laboratory fees, other diagnostic tests, medical reports,
medical records, medical testimony, and needed, interpreter's
fees, for the purpose of proving or disproving a contested claim.
(Lab. Code § 4620.)
Panel Decision:
“…lien claimant is not required to pay a lien activation fee
prior to a 2013 lien trial where: (1) the declaration of readiness
(DOR) is filed prior to January 1, 2013; (2) the lien conference
takes place prior to January 1, 2013; and (3) the lien trial takes
place in 2013, without any intervening 2013 lien conference."

Panel Decision:
Petitioner has not provided any specific examples of alleged
error by the WCJ and has failed to
cite to the record in any way whatsoever.
Panel Decision:
The [WCAB] shall not designate a party or lien claimant, or
their attorney or agent of record, to serve any final order,
decision, or award relating to a submitted disputed
issue."

Panel Decision:
(1) a claim for medical-legal expenses may not be filed as a
petition for costs under section 5811.

Panel Decision:
In her Report, the WCJ stated that lien claimant consistently
argued that the settlement agreement did not address the entire
lien
Panel Decision:
The undersigned is perplexed as to why a member of the bar
would rely on a letter to which there was no response by the
Workers Compensation Appeals Board to assume or presume
that no appearance was required when Notice of Hearing was
sent and received.


Panel Decision:
Have to Love Judge Thompsons’ Humor in this decision: “So
what shall we do when faced with a “bogus” Declaration of
Readiness” (DOR)?

Penal Decision:
In order to obtain an order pursuant to section 4903.6LC must
file a petition specifying the  medical information to be
provided and the relevance of that information to the proof of
the reasonableness and necessity of the services that are the
subject of LC's lien.\

Panel Decision:
More important, his allegation of "technical difficulties" in
paying the lien activation fee, without reference to any
specifics or evidence to support the allegation, is the same
thing as outright misrepresentation.
Panel Decision:
The mailing of an item to a correct address creates a
presumption that that document was received. (Evid. Code see.
641.) However, the presumption is rebuttable, and in my view
was properly rebutted by the timely objection to the second
transmittal of the document, supported by a sworn declaration
of the mail clerk for Frontline's representative, Controlled
Health

Panel Decision:
The undersigned is perplexed as to why a member of the bar
would rely on a letter to which there was no response by the
Workers Compensation Appeals Board to assume or presume
that no appearance was required when Notice of Hearing was
sent and received.
Panel Decision:
Here, Lopez withdrew its lien prior to the date of the Martinez
decision, and there is no evidence that the lien has otherwise
been dismissed. Although Lopez's petition for costs must be
dismissed, it can  reinstate its lien and pay the lien activation
fee prior to the conference scheduled..."

Panel Decision:
Meanwhile, on January 1, 2013, section 4903.6(d) became
operative. That section provides: "With the exception of a lien
for services provided by a physician as defined in Section
3209.3, no lien claimant shall be entitled to any medical
information, as defined in subdivision

Panel Decision:
In Figueroa, the Board stated that '(1) the lien activation fee
must  be paid prior to the commencement of a lien conference,
which is the time that the conference is scheduled to begin, not
the time when the case is actually called
Panel Decision:
Every petition for reconsideration "shall fairly state all of the
material evidence."

Panel Decision:
Defense Not Sanctioned for not verifying Petition for Recon
and for stating he did not understand the lien issues at Trial.
Panel Decision:
While I appreciate the special concerns arising from the huge
volume of lien litigation we are experiencing, I have also considered
that it seems quite unlikely that an applicant would have their case
dismissed or a defendant suffer a default judgment in a high-money
claim under similar circumstances.

Panel Decision:
But defendant's failure to conduct utilization review does not relieve
applicant of the evidentiary burden of showing, by a preponderance
of the evidence, that the requested medical treatment is reasonably
required to cure or relieve the effects of his injury.

Panel Decision:
The problem here is that there is no evidence that LCs received
notice of the lien conference on April 9, 2013. As the WCJ has
pointed out, LCs do not appear on the Official Address Record.
Panel Decision: In addition, we reject the petitioning lien
claimant's contention that because defendant failed to furnish
documents to lien claimant and failed to negotiate its lien,
petitioner is somehow excused from paying the lien activation
fee ("LAF"). The contention fails because the LAF is prerequisite
to invoking the jurisdiction of the WCAB to raise allegations
that defendant failed to negotiate, etc.

Panel Decision:"lien conference was due to inadvertence
/miscalendaring, relief should be granted pursuant to L. C. Section
§5506 and/or CCP § 473. However, these code sections only
apply to default judgments being entered against a party for its
failure to: appear. In this case, a default judgment (Order of
Dismissal)"

Panel Decision: However, our NIT was issued because lien
claimants filed a skeletal Petition for Reconsideration failing to
provide a statement of facts, to raise issues of contention, to
make arguments of law upon which reconsideration was sought,
or to identify the individual filing the Petition for
Reconsideration.

Panel Decision:We note, however, that the order does not
specify that Greenway's lien was dismissed with prejudice. Because
this case concerns a filing fee and not an activation fee, upon
return to the trial level Greenway may re-file its lien, provided  
that it does so within three years from the date that services were
provided and contemporaneously pays the required lien filing fee.
(Lab. Code, § 4903.5(a).)
Panel Decision:
Essentially, lien claimant contends that its failure to appear at the
April 15, 2013 lien conference was due to inadvertence because it
had miscalendared this matter.

Panel Decision: In addition, we reject the petitioning lien
claimant's contention that because defendant failed to furnish
documents to lien claimant and failed to negotiate its lien.*
Panel Decision: -17
However, procedural rules, such as the service of orders under
Rule 10500, serve the convenience of the WCAB and they do
not  deprive it of the power to disregard violations where there is
no substantial prejudice to the parties."

Panel Decision:
In addition, we reject the petitioning lien claimant's contention
that because defendant failed to furnish documents to lien
claimant and failed to negotiate its lien, petitioner is somehow
excused from paying the lien activation fee ("LAF").

Panel Decision:
provides no evidence that it actually attempted to pay the fee, It
provides no evidence as to the exact problems encountered when
it allegedly tried to pay the lien activation fee. Further, lien
claimant has had ample opportunity to pay the fee since January
1, 2013.

August 29, 2013: Injunction for Dismissals 01/2014 that do not
show a lien fee dismissed by operation of law Scheduled Oct 24
2013;
What it means if rant and what it means if denied.
Panel Decision:
"due to human error" and that its lien representative was at the
Marina Del Ray District Office on the day of trial but failed to
sign in "for reason unknown." However, we find that the claim
of "human error ... for reason unknown" does not  rise to the
level of good cause." 21

Panel Decision:
Due process simply requires notice and an opportunity to be
heard. If a party does not take advantage of that opportunity,
then it waives its right to be heard.
Panel Decision:
From Recent Panel Decision: Because lien claimant did not have
a lien in ADJ7541189, the order dismissing a (nonexistent) lien
has no effect and lien claimant is not aggrieved by the WCJ's
Order

Panel Decision:
Petition falls within Appeals Board Rule 10561, subdivisions
(b)(2), (b)(5), and (b)(6) because it was filed without justification,
appears to contain multiple material misrepresentations, and
takes positions that are indisputably without merit. -25
Panel Decision:
It is clear under [section 4903.8(e),  that if the lien is filed after
January 1, 2013 and violates this section it is invalid.
Panel Decision:
Finally, we admonish petitioner that his failure to adhere to the
form requirements of petitions for reconsideration is conduct
that is unacceptable. With respect to the form of the Petition,
Panel Decision:
If Dismissed by Operation of Law cannot be with prejudice:

Panel Decision:
No Letter of Rep -Petition  for Recon Dismissed as filed by a
NON-Party

Case Law, The Case That Changed Everything for Providers
at the WCAB, must be read and Known
Panel Decision: - AME-Medical Leag
Communications with AMEs are governed by Labor Code section
4062.3 and WCAB Rule 35. "If an agreed medical evaluator is
selected.., the parties shall agree on what information is to be
provided to the agreed medical evaluator." "All communications
with an agreed medical evaluator... shall be in writing and shall be
served on the opposing party 20 days in advance of the
evaluation.

Panel Decision:
lien claimant never mentions the issue of whether lien claimant
met its burden to show that its medical services were medically
reasonable and necessary

Panel Decision:
The WCJ further found that applicant did not receive notice of
defendant's Medical
Provider Network [MPN] prior to her injury and that a letter
sent to applicant on May 4, 2010 did not comply with MPN
notice requirements.

Panel Decision:
Petition for Costs Medical Legal
Panel Decision:
sanctionable conduct includes "using any language in any pleading or
other document [.. .] where the language or gesture impugns the
integrity of the Workers' Compensation Appeals Board or its
Commissioners,
judges, or staff.

Panel Decision:
Petitioner argues that due to an EAMS scheduled maintenance
Petitioner was unable,to pay the activation fee. Although Petitioner
states their inability to pay the activation fee due to regularly
scheduled maintenance, Petitioner offers no offer of proof of this
in the Petition.
Panel Decision:
Finally, it is noted that the record contains no requests for
authorization regarding the treatment at issue. In order to meet its
burden of proof, Lien Claimant must show that authorization for
the treatment was properly requested.

Panel Decision:
Reconsideration may be had only of a final order, decision, or
award. (Lab. Code, § 5900.)
NELAYNE VALDEZSUPREME COURT OF CALIFORNIA  -
MON Admissible of Reports outside MPN

: Panel Decision:
Between the Petition and the July 30, 2012 lien conference, we
have three purported lien representatives for a single lien claimant.
The record in this matter lacks the appropriate notice appointing
Panel Decision:
Failure of PTP to incorporate does not mean the secondary /
consultant does not get paid
: Panel Decision
Dr. Massey had not yet adopted Dr. Newman's findings does not
mean the latter physician's reports were not reasonable and
necessary at the time the expenses for the reports were incurred
Panel Decision:
As all of the requirements have been met, it is appropriate for
Dr. Newman to bill for his evaluation and reports as a
medical-legal expense, rather than services payable pursuant to
the OMFS. Here, Dr. Newman was designated by the primary
treating physician -
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DME Providers
Medical Testing
Primary Treators
Chiropractic
Physical Therapists
Response to NOI Dismissal
Response to NOI sanctions
Points and authorities for trial
Petitions for Reconsideration
Response to Petition for Reconsideration
Petition to Enforce IBR
Petition for IBR Ineligibility Requirement
Petition to Appeal IBR Decision

Petition for Medical Information by a
Non-Physician Lien Claimant

Petition for a Non-IBR Medical Legal Dispute
New One Line Program: Requests for Authorization: Adding new feature that lets providers review what UR and IMRs are looking for to authorize specific treatment requests in
a matter of seconds to make sure RFAs are compete and requesting proper and correct treatment. --  Updated Daily Several New and Existing Decisions will Be added Daily
By Billing Code ---New IBR Decisions  added as New Decisions  Made  --Each
Billing Code Represents Several IBR Decisions
 


00300 QZ 6 Anesthesia services

0060 QZ (9)Anesthesia Services / Requested PPO non-supplied

00630Anesthesia Services

00750; 94760Anesthesia Services

11100Surgical Facility Services

11100 / 11101Surgical Facility Services

11100 59Surgical Procedure

11101 59 / 17002Surgical / PPO contract is Incomplete so applied fee schedule

12001Surgical Procedure

15740 / 17311 / 17106 / 11100 / 11101Surgical Center

17002Cryosurgery Procedure

17002Surgical Procedure

17002 (11)Surgical Procedure

17002 (16)Cryosurgery

17002 (25)Surgery Destruction of Lesion

17034 / 17107Surgical Procedure

17034 / 17999Surgical Procedures

17106 (17999) / 11100 / 11101Surgical Facility Services

17304 / 1799 /Surgical Procedures

17304 / 17999 59 / 11100 59 / 11101 59 /Surgical Procedures

17304 and 17999 Modifier 59Surgical Procedures

17304; 17304 modifier 59; 17999 modifier 59; 17999 modifier 59        Surgical Procedures

17304; 17999Surgical procedures

18860072210Pharmaceutical Supplies

20550 Modifier 51Surgical Procedure

20680 / 20680 / 20680 / 29125Surgical Facility Services /

22110 /22110 59 / 22116 / 22116 59 / 76001 / 64830 Multiple Surgical Procedures / 22554; 22851;
22851 59 –

ASC ServicesSurgical Facility Services

22830; 22855; 63090; 63091; 63047Spinal surgery: two stages and co-surgeon involved

24102; 25290; 24341 Surgical Facility Services

24314Surgical Facility Services

24314; 25290Surgical Facility

25000 Modifier 51Multiple Surgical Procedures

26145 x 9 units Surgical Center /

26145; 26055Surgical Facility Services

26370; 26373; 26373; 20103Surgical Facility Services

274 Revenue CodeUpper limb orthosis (L3999)

27422; 29870; 29881; 29875Surgical Facility Services

27570 / 29870Surgical Procedures

27570 / 29870 / 20610Surgical Procedures

27625; 29898; 20605Surgical Facility Services

27685Surgical Procedure

29805;29821;29807;29826;29827;29819;29999Surgical Facility Services

29819 / 29820Device  for surgical procedure

29823Surgical Procedure /

29823Surgical Procedure

29823 Modifier RT  Surgical Procedure

29823; 29826; 29827; 23120; 20690; 29805;Surgical Facility Services

29824Surgical Facility Services

29825 (51)Surgical device for outpatient surgery

29846 / 64721Outpatient Hospital Services

29876 / 29870 / 27570 Surgical Facility Services

29880 / 29877 / 29874 / 29875 / 20610Surgical procedures

29881 / 29875        Surgical Facility

29881 / 29875Surgical facility Services

29888Surgical Facility Services

37720 / 76942 / 93971Laser Procedure and unlisted

37785 / 76942 / 93971Laser procedures

37799 (37720; 76949 26 and 93971 26)Surgical Procedures

37799 (37785, 76942 26 and 93971Surgical Procedures

37799 and  9908037799 laser procedure  / 99080 by report

38779056104Pharmaceutical Supplies

38779056104 / 38779175603Pharmaceutical Supplies

38779056104 /38779175603Pharmaceutical Supplies

45861000405 NDCMedrox Patches

49452003202 / 38779052409  / 62991142202Compound Drug Product

58468009001Pharmaceutical

58468009003 (NDC) 12 unitsPharmaceutical Supplies

62991140305Pharmaceutical Supplies

62991140307Pharmaceutical Supplies

63047 / 63048 / 63048 59Surgical Facility

63091 62Surgical Procedural two/co-surgeon

63660 / 63660 59Removal of spinal Cord Stimulator Test Leads

63685 / 76496 TCSurgical facility / Corrected Billing Code

63685 and 76496Surgical Facility

64483 / 72100 / 76000 / 94760Surgical Facility services

64484 / 64483Surgical Facility

64484 rt / 64484 ltOutpatient Surgical Facility

64555 59Surgical Facility

64719 51Surgical Facility

64722 (59)Surgical Facility

64830 20 / 72100 / 72148 26Surgical Procedural

64999 (63047)Unlisted Procedure Nervous System

80102 and 82486Laboratory Services

82055 / 80299 59 / 80299 59 / 83925 59 / 83986 / 83992 / 81002 / and 80152        Laboratory
Services

82055; 82145; 82205; 80299 (2); 82520; 83840; 83925 (3); 83986; 83986; 83992; 81002 and
80152        Laboratory  Services

82145 / 82205 / 80154 / 82520 / 83992 / 83925 / 82145 / 82055 / 82570        Laboratory Services

82145(2); 82205; 80154; 82520; 83840; 83840; 83992; 83925 (2)        Laboratory Results

82145/ 82205/ 82520 / 83840 / 83992 / 83925 / 82145 / 82055 / 82570        Toxicology

82145; 82205; 80154; 82520; 83840; 83840; 83992; 83925; 83925 mod 59; 8214559; 82055 and
82570        Laboratory Services

82145; 82205; 80154; 83480; 83992; 83925 modifier 59; 82542 and 82145 modifier 59        
Laboratory testing

82415; 82205; 80154; 82520; 83840; 83992; 83925; 82145        Laboratory Results

82486 Laboratory Services

88305Pathology services

90862 / 99081        Medication Management Services

93320 / 93325Echocardiography services

95904Nerve conduction Studies

96100Psychological Testing / ML

96360 and 99284Emergency Department Services billed by an Outpatient Hospital Facility

96530 modifier 59Refilling and maintenance of implantable pump services

97799Unlisted Physical Medicine Service

99080Consultation Report
\
99080Review of Records: Initial Comprehensive Dermatologic Evaluation Report

99080Special Reports

99080Initial Comprehensive Preoperative  Consultation Report

99080 86 / 99358Prolonged Services

99081PTP Progress Report

99081PR-2

99085 / 99080 / 99358Prolonged Services

99086 / 99085 / 99080 / 17999Prolonged Services

99213Office Visit

99213Evaluation and Management

99214 Visit

99215Evaluation & Management

99244Office consultation

99354Prolonged Office Visit

99358Prolonged Evaluation

99373Evaluation & Management  (phone call)

99373 / 99081Phone Call and Required Report

ASC Facility Services        Outpatient Surgery

Compound Medication / Prialt 18860072010        Compound Medication

Compound Medication / Prialt 18860072010        Compound Medication

Consolidation DME        DME E0214 Sample of Consolidation

DRG 454        Inpatient Hospital Services

DRG 455        Inpatient Hospital Services

DRG 459 Inpatient Hospital Services

DRG 460 Inpatient Hospital Services

DRG 473       Inpatient Hospital Services  

DRG 491        Inpatient Hospital Services

DRG 494 Inpatient Hospital Services

E1399Durable Medical Equipment

E1399  LL (3 units) Durable Medical Equipment

E1399 (LL) (6)Durable Medical Equipment

E1399 LL (7 units)Durable Medical Equipment

E1399 modifier LLDurable Medical Equipment

G0431Laboratory Services

L0635        Orthotic Device part of DGR 455

L1990 / and Outlier for Outpatient         Outpatient Hospital Surgical Services

L4360 / and Outlier for Outpatient         Outpatient Hospital Surgical Services

L86999 / C9399 Surgical Facility

ML 104 (46) / 96100Medical Legal Services

ML 104 (90801 and 99358 8 unitsMedical Legal services

ML 104 93 unitsMedical Legal Services

ML 104 94Medical Legal Services

ML 104 Modifier 94 (62 units)ML Extraordinary  (Psychiatric  Eval)

ML 104 modifier 94 and 95ML

ML 104 Modifier 95 (23) units

ML 106 Mod 94 / ML 100 Mod 94Medical Legal services Reports

ML=103 reduced to ML 101Medical Legal Services

ML=104 95 (20)Medical Legal  Services

ML0104 94 / 99070Medical Legal and Supplies

ML104 Modifies 95Reviewed as a ML 103 Modifier 95 (1 unit)

Outpatient Hospital Emergency Room Services

Outpatient Surgical Services        
Alert New IBR Decisions  Posted

September 29, 2014: New IBR Decisions Posted: All Three Additional Monies Owed to Provider

-63047  /63048



-22/830 /22855 / 63090 / 63091



-82145 /82205 / 80154 / 82520 / 83480 / 83992 / 83925 / 83925 59 / 82145 59 / 82055 / 82057
New IMR Decisions  Posted September 2014
Errors on Documentation and Requests
Drug Testing   
Toxicology Should
Always be reasonable
and necessary