Maxine Wiggs was injured while working for Allied Signal Aerospace. Wiggs had six surgeries from 1998 through 2012. By the time of her surgery in 2012, Wiggs was on multiple opioid and narcotic medications for pain management. Wiggs had three more surgeries from 2014 through 2017.
A dispute arose over home health care services. The parties stipulated in 2012, that Irene Mefford was the agreed registered nurse to perform a home assessment for housekeeping services. Mefford was to prepare a report, which should be sent to Wiggs’ doctors for review and comment;
Mefford’s report, issued on February 11, 2013, recommended Wiggs be provided with housekeeping services two times a month (approximately four hours per visit) for the purposes of housecleaning duties for the duration of one year. The employer authorized home care for one year and also paid for retroactive home care in the amount of $5,507.
On March 7, 2014, Wiggs’s primary treating physician submitted an RFA for home care. Allied’s UR authorized home care on March 14, 2014. The authorization was for four hours twice a month for deep cleaning assistance.
As a result of Wiggs’s additional surgeries, on June 18, 2015, Wigg’s physician requested authorization for four hours of house cleaning every week. Allied’s UR denied authorization for increased house cleaning home care. Wiggs did not seek an IMR of the UR denial. The record includes multiple RFAs included within progress reports of Wiggs’s doctors for four hours of house cleaning per week. The most recent RFA for four hours of home health care per week was submitted on April 6, 2016.
Wiggs thereafter filed for an expedited hearing on the issue. Wiggs argued that Allied’s failure to submit the April 6, 2016 RFA for home health care to the UR process had the effect of entitling her to home care. Allied argued that the April 6, 2016 RFA was identical to an earlier denied RFA, which could not be asserted without any change in circumstance in Wiggs’s condition. Neither Wiggs nor Allied at this point raised an ongoing stipulation to utilize Mefford for any disputes arising out of home health care.
The WCJ ordered Allied to serve Mefford with Wiggs’s medical reports from March 10, 2012 through October 19, 2016. The WCJ ordered Mefford to prepare a supplemental report after review of the medical records, a home assessment, and interview with Wiggs. The report was to address whether as a result of her industrial injuries, Wiggs was in need of heavy home health care.
A majority of the appeals board affirmed the WCJ’s decision to develop the record and incorporated and adopted the WCJ’s opinion and report. However the court of appeal reversed in the unpublished case of Allied Signal Aerospace v. Workers’ Comp. Appeals Bd.
The court of appeal ruled that “the issue of home health care for Wiggs is an issue to be resolved in and by the UR process, not the WCJ or the appeals board. … the WCJ and appeals board do not have jurisdiction to address and resolve the issue of home health care for Wiggs.”