Applicant, Jian Kallash while employed on April 6, 2019, as a Sales/Customer Service Associate at National City, California, by Macy’s West Stores, Inc., sustained injury arising out of and in the course of employment to the lumbar spine.

Applicant’s secondary treater, Dr. Abitbol, submitted an RFA dated March 18, 2024. Defendant untimely issued a UR denying such requests for treatment such that the parties proceeded to trial from an Expedited hearing on such issue of treatment.

The WCJ issued a Findings and Award/Opinion on Decision on December 20, 2024 and awarded the treatment. The Petition for Reconsideration of the award was was denied for the reasons stated in the WCJ’s Opinion on Decision and the Report, both of which it incorporated in the WCAB panel decision of Kallash v Macy’s West Stores, Inc.,– ADJ12663627 (March 2025)

The employer contended that the WCJ erred in granting the requested treatment arguing the WCJ failed to reference any MTUS provision or supporting evidence-based medical or scientific guideline in support of the award of the requested treatment over the utilization review non-certification, And failed to show the MTUS or evidence-based medical and/or scientific guidelines were rebutted by substantial medical evidence.

Defendant cites the panel decision of Thompson v. County of L.A. (2016 Cal.Wrk.Comp. P.D. Lexis 107) and Rios v. S. San Francisco Unified Sch. Dist. (2021 Cal.Wrk.Comp. P.D. Lexis 15).

In Thompson, the applicant was not entitled to the requested lumbar surgery because the requesting physician failed to reference either MTUS or other evidence-based guides to support the treatment modality. That case refers to a physician failing to justify the request, not the WCJ.

Currently, what defendant has not shown is that the WCJ must specifically reference the MTUS guidelines, ACOEM guidelines or any other evidence-based treatment guidelines to substantiate the requested treatment. In fact, in reviewing the findings of the untimely UR denial, such denial itself failed to state or reference any MTUS updates or ACOEM guidelines in which they based their denial.

The untimely UR denial only states that, “The records did not document failure of non-operative measures for the claimant. No formal physical therapy records for the claimant were included for review detailing response and lack of progress with treatment. No recent medications for pain or injections were detailed. Further, review of the lumbar imaging report did not detail evidence of any spondylolisthesis with motion segment instability at L5-S1 measuring 5mm or more. The current evidence-based guidelines do not recommend lumbar spine fusion to address lumbar spondylosis or radiculopathy only.”

The WCJ in his Response to the Petition for Reconsideration notes that “There is no mention of the MTUS guidelines or ACOEM guidelines or a reference to any other evidence-based guidelines to explain the denial. Records presented to the WCJ to review in assessing the reasonableness and necessity of the treatment were not sent to UR. It was this lack of the medical evidence provided to the UR department that created the original denial.”

“Had the adjuster been forthcoming with the complete medical file, UR may not have denied the necessary treatment. Furthermore, as previously stated in the Opinion on Decision, the evidence clearly established that applicant had exhausted all conservative treatment and the EMG and MRI studies revealed positive findings. (Court Exhibit JJ) The medical evidence, taken as a whole, between the multiple treaters and the QME establishes the medical necessity of the requested surgery.”