In November 2016, Orlando Rodriguez suffered severe head and brain injuries while working as a mechanic for Managed Mobile, Inc. His employer’s insurer, Illinois Midwest Insurance Agency LLC, acknowledged the injuries as work-related and began providing compensation benefits.
Starting in September 2018, Rodriguez’s primary treating physician, Dr. Yong Lee, repeatedly requested authorization for home health care services in six-week increments to support Rodriguez’s recovery. Illinois Midwest approved at least eight such requests between September 2018 and August 2019, sometimes directly by a claims adjuster and other times after subjecting them to utilization review.
However, when Dr. Lee submitted a new request for authorization on September 12, 2019, Illinois Midwest forwarded it to utilization review. On September 19, 2019, the reviewing physician denied the request, deeming the ongoing home health care no longer medically necessary. Rodriguez challenged this denial not through the statutorily required independent medical review (IMR) process, but by seeking an expedited hearing before a workers’ compensation administrative law judge (WCJ) at the Workers’ Compensation Appeals Board (WCAB).
In March 2020, the WCJ ruled in Rodriguez’s favor, awarding him ongoing home health care. The judge reasoned that since the treatment had been previously authorized and Rodriguez’s need was “ongoing and constant,” Illinois Midwest could not terminate it without demonstrating a substantive change in his medical condition – a showing the insurer had failed to make.
This decision relied heavily on a non-binding WCAB significant panel decision in Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910 [2014 Cal. Wrk. Comp. P.D. LEXIS 98] (Patterson), that suggested employers must continue providing authorized ongoing treatments unless circumstances change, without restarting the review process.
A significant panel decision is a decision of the Appeals Board that has been designated by all members of the Appeals Board as of significant interest and importance to the workers’ compensation community. Although not binding precedent, significant panel decisions are intended to augment the body of binding appellate and en banc decisions by providing further guidance to the workers’ compensation community. (Cal. Code Regs., tit. 8, § 10305(r).)
The WCJ also noted that the facts presented were similar to those considered in Warner Brothers v. Workers’ Comp. Appeals Bd. (Ferrona) (2015) 80 Cal. Comp. Cases 831, 832-834 (writ denied), wherein the Appeals Board panel affirmed the trial judge’s finding that the reasoning in Patterson applies to assistive home care
Illinois Midwest petitioned the WCAB for reconsideration, arguing that the WCJ lacked jurisdiction because medical necessity disputes must be resolved exclusively through utilization review and IMR under reforms enacted in 2004 and 2013. These reforms aimed to shift such decisions from judges and courts to medical professionals, using evidence-based guidelines like the Medical Treatment Utilization Schedule (MTUS) to control costs and ensure quality care.
In January 2025 – after a nearly five-year delay – the WCAB affirmed the WCJ’s ruling, again invoking Patterson and concluding that Illinois Midwest bore the burden of proving changed circumstances to justify ending the treatment. It cited Patterson (supra)
Illinois Midwest then sought review in the California Court of Appeal. The Court of Appeal annulled the WCAB’s decision in the published case of Illinois Midwest Ins. Agency, LLC v. WCAB -B344044 (November 2025).
The Court of Appeal held that the WCAB exceeded its jurisdiction by bypassing the mandatory utilization review and IMR processes. It emphasized that the 2013 reforms (via Senate Bill No. 863) made IMR the sole avenue for appealing adverse utilization review decisions for injuries occurring after January 1, 2013, or denials communicated after July 1, 2013 – criteria met in Rodriguez’s case.
The Court of Appeal rejected any exception for “ongoing” or “continual” treatments, distinguishing and limiting Patterson to pre-2013 contexts where IMR was not yet exclusive. “We reject Patterson v. The Oaks Farm (2014) 79 Cal.Comp.Cases 910 (Patterson) to the extent it set forth a contrary rule for injuries or medical necessity determinations arising after the 2013 reforms.”
It clarified that even for extended treatments like home health care, each new request for authorization triggers the statutory review process, and the burden remains on the worker to prove ongoing medical necessity through medical evidence, not on the employer to prove changed circumstances.
The court underscored the legislative intent: to ensure medical professionals, not judges or courts, make medical necessity determinations, promoting efficiency and evidence-based care. By allowing the WCAB to intervene, the lower rulings had undermined this framework.
The case was remanded for proceedings consistent with the opinion, effectively requiring Rodriguez to pursue any further challenge through IMR if he sought to overturn the denial.
