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IMR Required Despite No Substantive Change in Med Condition

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 Although not binding precedent, significant panel decisions are intended to augment the body of binding appellate and en banc decisions by providing further guidance to the workers’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.

Top 10 OSHA Violations Topic at NSC Safety Congress & Expo

The Occupational Safety and Health Administration on Tuesday announced its most frequently cited workplace safety standards for fiscal year 2024.

Scott Ketcham, director of the directorate of enforcement programs for OSHA, together with Safety+Health magazine presented the preliminary data for OSHA’s Top 10 during the 2024 NSC Safety Congress & Expo, the world’s largest annual gathering of safety professionals.

Fall Protection – General Requirements remains at the top of the list for the 14th year in a row, followed by Hazard Communication and Ladders.

“While incredible advancements are made in safety each year, we continue to see many of the same types of violations appear on OSHA’s Top 10 list,” said Lorraine Martin, NSC president and CEO. “As a safety community, it’s critical we come together to acknowledge these persistent trends and identify solutions to better protect our workforces.”

The Top 10 most frequently cited workplace safety standards for FY 2024 are:

1. Fall Protection – General Requirements (1926.501): 6,307 violations
2. Hazard Communication (1910.1200): 2,888
3. Ladders (1926.1053): 2,573
4. Respiratory Protection (1910.134): 2,470
5. Lockout/Tagout (1910.147): 2,443
6. Powered Industrial Trucks (1910.178): 2,248
7. Fall Protection – Training Requirements (1926.503): 2,050
8. Scaffolding (1926.451): 1,873
9. Personal Protective and Lifesaving Equipment – Eye and Face Protection (1926.102): 1,814
10. Machine Guarding (1910.212): 1,541

A more in-depth analysis of the Top 10 violations for 2024 will be published in the December edition of Safety+Health magazine, a National Safety Council publication.

The National Safety Council is America’s leading nonprofit safety advocate – and has been for 110 years. As a mission-based organization, we work to eliminate the leading causes of preventable death and injury, focusing our efforts on the workplace and roadways. We create a culture of safety to not only keep people safer at work, but also beyond the workplace so they can live their fullest lives.

November 3, 2025 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Trader Joe’s Successfully Defends Worker’s Retaliatory Termination Case. Visiting Store Just to Build a Lawsuit No Defense to Unruh Damages. CDC Adopts Individual-Based Decision-Making for COVID-19 Shots. DOI Seeks Public Input on Proposed Long-Term Solvency Regulation. DWC Opens Registration for 33rd Annual Educational Conference. NCCI Reports on Remote Work and WC Frequency. DWC Posts Draft Regulations Updating EAMS Rules. New Drug Launch Price Increases Exceed Inflation Benchmarks.

L.A. Fire Survivors Call for Insurance Commissioner Resignation

Survivors of the Eaton and Palisades fires on Thursday urged Gov. Gavin Newsom to call for the resignation of California Insurance Commissioner Ricardo Lara, following a front-page New York Times report revealing that Lara privately struck a deal with insurers allowing them to drop tens of thousands of policyholders ahead of the Los Angeles fires.

The New York Times investigation, based on internal state documents and communications, found that in 2023 Lara struck a secret deal with insurance companies that incentivized them to dump tens of thousands of policyholders in exchange for future rate hikes. The deal was sold to the public as a way to keep people out of the state’s high-cost, low-benefit FAIR Plan, but just the opposite happened. FAIR Plan nearly doubled, and many families lost coverage just months before the Los Angeles fires.

At a press conference in Altadena, survivors point to this and their own experience to say that California now faces two crises: families who can no longer buy or renew insurance, and those who still have coverage but cannot access the benefits they’ve already paid for. Both failures, survivors said, fall under Lara’s leadership – and now sit on the governor’s desk.

Joy Chen, executive director of the Eaton Fire Survivors Network and a former deputy mayor of Los Angeles, said:

“Families can no longer buy or renew coverage, and those who still have it can’t access the benefits they’ve already paid for. Californians can’t afford another year of failed oversight. This crisis now sits on the governor’s desk. Governor Newsom should call for Commissioner Lara to resign and install leadership that enforces the law and restores public trust.”

A Department of Angels report found that 70 percent of insured Eaton and Palisades survivors face systemic underinsurance and delays and denials blocking their recovery. A second Department of Angels report, released in October 2025, found that more than eight in ten Los Angeles fire survivors remain displaced, with most expected to lose their temporary housing coverage within months. With coverage expiring in real time, families are being forced out of rentals now – a slow-motion disaster unfolding as state leaders fail to act. Survivors described widespread, needless suffering among tens of thousands of Los Angeles fire survivors – families still displaced, underinsured, or denied the benefits they’ve paid for.

Branislav Kecman, an Eaton Fire survivor, said his family paid premiums to State Farm for 12 years before being dropped just months before the fire. The cancellation forced them onto the state’s FAIR Plan, which costs more and covers less.

“That was painful enough,” he said. “But what’s truly devastating is learning that our own Insurance Commissioner secretly cut a deal that encouraged insurers to drop families like ours. We thought we could trust the system. We never imagined we’d be betrayed by the very person elected to protect us.”

Jill Spivack, a longtime Pacific Palisades resident and State Farm policyholder whose home burned in the Palisades Fire, said what began as heartbreak has turned into outrage.

“After the fire, I thought we were protected – we’d paid State Farm for 25 years. But the real disaster was the endless maze of delays and denials. I had to put my business on hold just to fight for what we’d already paid for. Governor Newsom, your words gave us hope. Now we need your actions to make that hope real. Californians deserve an Insurance Commissioner who protects families, not the insurers doing the most harm.”

Consumer Watchdog Executive Director Carmen Balber said Lara’s secret deal exposed a crisis of leadership that can only be resolved by the Governor.

Survivors warned that Los Angeles stands on the edge of a second catastrophe – one of permanent displacement. Lara has approved billion-dollar rate hikes for the state’s largest insurer, State Farm, while 82 percent of its policyholders report negative claims experiences.

A Los Angeles Times analysis found that five major California wildfires between 2017 and 2020 destroyed 22,500 homes – and by 2025, only 38 percent had been rebuilt. The Times identified insurance as the single biggest factor determining recovery: when insurance paid promptly, families rebuilt; when it didn’t, most never recovered.

The Eaton Fire Survivors Network, representing more than 8,500 Californians, has documented nearly 500 firsthand accounts of insurer misconduct and delivered a five-step enforcement plan to Commissioner Lara.. Every elected official representing the Eaton and Palisades fire zones – including Senators Sasha Renée Pérez and Ben Allen, Assembly members John Harabedian and Jacqui Irwin, Supervisor Kathryn Barger, Mayor Karen Bass, and Altadena Town Council President Victoria Knapp – has joined survivors’ call for accountability.

In closing, Chen added: “Let our Los Angeles experience be a warning to every Californian. Our entire housing market will collapse if families can’t buy or renew insurance, and if those who have it can’t get the benefits they’ve paid for. California cannot afford another year of Ricardo Lara. We call on Governor Newsom to act now: urge Commissioner Lara to resign, and install new leadership that enforces the law and rebuilds a functioning insurance market.”

Novartis Opens New Manufacturing Facility in Carlsbad

Novartis announced the opening of a new 10,000-square-foot radioligand therapy (RLT) manufacturing facility in Carlsbad, California. This state-of-the-art site represents a key milestone in the company’s previously announced $23 billion investment in US infrastructure over the next five years.

The opening of the Carlsbad manufacturing facility allows Novartis to seamlessly meet future demand for RLT, adding additional capacity and augmenting the company’s world-class supply chain capabilities. The Carlsbad facility has been filed with the FDA as an additional US point of supply, and commercial manufacturing may begin once approval is granted.

RLTs are a form of precision medicine that combines a tumor-targeting molecule (ligand) with a therapeutic radioisotope, enabling the delivery of radiation to the tumor with the goal of limiting damage to the surrounding cells. Because each RLT dose is custom-made and time-sensitive, with a radioactive half-life measured in hours, proximity to treatment centers and transit hubs helps ensure patients receive their treatment when and where they need it.

Novartis is the only pharmaceutical company with a dedicated commercial RLT portfolio, and the Carlsbad facility is its third US RLT manufacturing site, reinforcing its global leadership in radioligand therapies with unmatched expertise in development, production, and delivery to patients worldwide. The Carlsbad facility is purpose-built to manufacture the company’s FDA-approved RLTs with capacity for future expansion.

“We commend Novartis for supporting our broader mission of bringing manufacturing capacity in the United States,” said FDA Commissioner Marty Makary, M.D., M.P.H.. “Our unique partnership approach is working.”

“Novartis is transforming the future of cancer care – and it’s happening right here in Carlsbad,” said Carlsbad City Council Member Melanie Burkholder. “This new advanced RLT production facility is a major milestone for our region, strengthening California’s position as a hub for life sciences innovation. It will bring exciting new opportunities for our community, including more engineering and manufacturing jobs. I’m proud our local community will be part of the future of cancer care.”

In addition to the Carlsbad opening, Novartis has announced multiple construction initiatives and future plans in the US, including:

– – Two additional RLT manufacturing facilities in Florida and Texas.
– – Expansion of existing sites in Durham, North Carolina, Indianapolis, Indiana, and Millburn, New Jersey.
– – Establishing its second global R&D hub in the US with a new state-of-the-art biomedical research innovation facility in San Diego, California.

These investments, enabled by a pro-innovation policy and regulatory environment in the US, reflect Novartis’ broad commitment to the market and building its infrastructure. Novartis expects to invest nearly $50 billion in its US operations over the next five years, including the $23 billion announced earlier this year, underscoring its long-term commitment to strengthening the US healthcare ecosystem.

Cal Supreme Court Says Criminal Misgendering Law is Constitutional

In 2017, the Legislature enacted the Lesbian, Gay, Bisexual, and Transgender Long-Term Care Facility Residents’ Bill of Rights. The legislation comprehensively addresses issues concerning lesbian, gay, bisexual, and transgender (LGBT) seniors’ access to, and treatment by, “[l]ong-term care facilit[ies] – an umbrella term covering entities that provide services ranging from skilled nursing to residential personal care for the elderly.

In December, just before the 2017 law went into effect, plaintiff Taking Offense (which describes itself as an entity dedicated to opposing efforts “to coerce society to accept [the] transgender fiction that a person can be whatever sex/gender s/he thinks s/he is, or chooses to be”) filed a petition for a writ of mandate in the superior court seeking to block enforcement of the pronouns provision as facially unconstitutional under the First Amendment to the United States Constitution. The lawsuit worked its way up to the California Supreme Court.

On November 6, 2025, the Supreme Court delivered a significant ruling in Taking Offense v. State of California (S270535), a case challenging a key provision of the 2017 Lesbian, Gay, Bisexual, and Transgender (LGBT) Long-Term Care Facility Residents’ Bill of Rights. This legislation aimed to fulfill existing anti-discrimination laws by explicitly prohibiting various forms of bias based on sexual orientation, gender identity, gender expression, or HIV status. The Legislature cited studies highlighting pervasive mistreatment of LGBT elders, including denial of admission, abrupt discharges, harassment, restrictions on visitation, and refusal to use preferred names or pronouns, often stemming from lifelong marginalization that left many without family support networks.

At the heart of the dispute was Health and Safety Code § 1439.51, subdivision (a)(5) – the “pronouns provision” – which makes it unlawful for facility staff to “[w]illfully and repeatedly fail to use a resident’s preferred name or pronouns after being clearly informed,” when motivated wholly or partially by the resident’s protected characteristics. Enforcement draws from pre-existing administrative, civil, and, in extreme cases, criminal penalties applicable to other violations in long-term care settings. Taking Offense, an unincorporated association of California taxpayers opposed to what it termed the “transgender fiction,” filed a pre-enforcement petition for writ of mandate in Sacramento County Superior Court in December 2017, seeking to block the provision as a facial violation of the First Amendment’s free speech protections.

The trial court denied the petition, upholding the provision against First Amendment challenges. On appeal, the Third District Court of Appeal partially reversed in 2021, deeming the pronouns provision overinclusive and insufficiently tailored to the state’s anti-discrimination interest, thus facially unconstitutional under heightened First Amendment scrutiny – whether viewed as content-based speech regulation or compelled speech. The appellate court emphasized that the law criminalized a viewpoint on gender identity without adequately advancing its goals.

The Supreme Court granted review. In a unanimous opinion the court first addressed standing, raised by the state for the first time on review. The justices agreed that the 2018 amendment to Code of Civil Procedure § 526a, which governs taxpayer standing, now limits such suits to local governments and excludes wholly state entities or officers. Tracing the evolution from common law taxpayer standing to the statute’s history, the court clarified that prior decisions blending the two doctrines no longer apply post-amendment. However, under the case’s unusual circumstances – including the state’s delayed objection, the parties’ full litigation of the merits, and the court’s own past expansive interpretations – the justices exercised discretion to reach the merits, avoiding an advisory opinion while deferring broader questions about common law or public interest standing.

On the substance, the court reversed the Court of Appeal, upholding the pronouns provision. Emphasizing the narrow context – vulnerable residents in a “captive audience” environment akin to their home, where staff provide intimate medical and personal care – the justices characterized the law as a regulation of discriminatory conduct that only incidentally burdens speech. Drawing on U.S. Supreme Court precedents like R.A.V. v. City of St. Paul (1992) and this court’s plurality in Aguilar v. Avis Rent A Car System, Inc. (1999), the opinion reasoned that anti-discrimination measures targeting hostile environments, such as workplace harassment, do not trigger First Amendment scrutiny merely because they involve words. The provision is carefully limited: it requires willful, repeated, knowing acts motivated by bias, exempts professionally reasonable clinical judgments, and does not bar staff from expressing gender views in other ways or contexts. Distinguishing cases like Reed v. Town of Gilbert (2015) and 303 Creative LLC v. Elenis (2023), which involved content-based restrictions in public forums or compelled expressive services, the court found no abridgment of free speech rights.

Even assuming intermediate scrutiny applied (as a content-neutral regulation), the provision was appropriate as it advances compelling state interests in protecting LGBT seniors’ dignity, access to care, and freedom from discrimination in a setting where avoidance is impractical, and it is narrowly tailored without restricting more speech than necessary. The court also rejected claims that potential criminal penalties – available only for egregious, unremedied violations after administrative processes – render the law facially invalid, noting their rarity and the Legislature’s intent to use them as a last resort.

Inland Empire Hospice Operators Sentenced in Fraud Case

Inland Empire Hospice operators, Ralph and Rochell Canales, were sentenced for submitting false claims to the Medicare and Medi-Cal programs. Ralph was sentenced by the San Bernardino County Court to seven years and four months in state prison and was jointly ordered to pay $1,455,233.

Rochelle was sentenced to one year in jail, and ordered to abstain from working with Medicare and Medi-Cal beneficiaries in a caregiver or fiduciary capacity and from working for any healthcare provider that receives funds from Medicare or Medi-Cal. The prosecution of these individuals was carried out by the California Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse.

From 2013 through 2022, Ralph Canales and his wife Rochell Canales, along with brother Sherwin Canales and business partners Giovanni and wife Maureen Ibale, operated Sterling Hospice, New Hope Hospice, River of Light Hospice, and Mt Olive Hospice in the Inland Empire. Ralph Canales played a primary role as owner and operator of these companies while his wife played a supporting role at the direction of her husband. While running these companies, these individuals paid illegal kickbacks, in the form of cash and personal checks, to illicit marketers and two Inland Empire-area doctors, who certified patients for hospice services though the patients were not suffering from conditions likely to be terminal.

Between the four companies, at least 52 patients were identified as being ineligible to receive hospice care substantially defrauding the Medicare and Medi-Cal programs. In addition to committing fraud against the Medicare and Medi-Cal programs, Ralph and Rochell failed to pay corporate taxes to the Franchise Tax Board and California Employment Development Department.

Since taking office, the current Attorney General said that he has filed criminal charges against 109 individuals with hospice fraud-related offenses and conducted 24 civil investigations, which resulted in multiple civil filings. Building on his efforts to combat hospice fraud, this August, the Attorney General launched a new initiative aimed at educating the public and providing vital reporting resources to individuals and families who may have been impacted by hospice fraud.

DMFEA works to protect Californians by investigating and prosecuting those responsible for abuse, neglect, and fraud committed against elderly and dependent adults in the state, and those who perpetrate fraud on the Medi-Cal program.

The Division of Medi-Cal Fraud and Elder Abuse receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $77,652,892 for Federal Fiscal Year (FFY) 2026.  The remaining 25 percent, totaling $25,884,297 for FFY 2026, is funded by the California Attorney General’s Office.  FFY 2026 is from October 1, 2025 through September 30, 2026.  

Uber/Lyft Sued for Passenger Gender Preference Programs

On November 3, 2025, two nearly identical class action lawsuits were filed in the San Francisco Superior Court, targeting the ridesharing giants Uber and Lyft for alleged sex-based discrimination against male drivers through preferential matching programs designed to prioritize female and nonbinary drivers for certain passengers.

In the case of Almond and Ruud v. Uber Technologies, Inc., plaintiffs Andre Almond and Hans Ruud – both allegedly highly rated, long-term male independent contractors who have driven for Uber in California for over seven and ten years, respectively – accuse Uber of unlawfully implementing its “Women Preferences” program on August 13, 2025, in Los Angeles and San Francisco.

This initiative, which Uber had piloted globally since 2019 in over 40 countries and completed more than 100 million sex-segregated rides, allows female riders to request female drivers via in-app settings, effectively reserving access to roughly half the passenger pool (female riders) for the 20% of drivers who are women.

Male drivers like the plaintiffs, who represent about 80% of Uber’s workforce and allegedly have spotless safety records with female passengers, are systematically excluded from these matches, resulting in lost income, fewer ride opportunities, reputational harm from implied unsafety stereotypes, and strained rider relationships.

Despite alleged internal memos from 2022 highlighting “significant legal risk” under U.S. anti-discrimination laws – and delays in domestic rollout due to counsel’s warnings – Uber proceeded, promoting the feature for “safety and confidence.”

The suit claims this violates California’s Unruh Civil Rights Act, which broadly prohibits arbitrary sex discrimination in business establishments and entitles victims to at least $4,000 in statutory damages per violation. It is seeking class certification for over 80,000 affected male California drivers, the plaintiffs demand declaratory and injunctive relief to halt the program, plus actual, punitive, and compensatory damages, restitution, attorneys’ fees, and a jury trial.

Also on November 3, the same lawfirm filed Kennedy v. Lyft, Inc.- which brings forth plaintiffs William Kennedy and Louie Alatorre – fellow veteran male Lyft drivers from Los Angeles County allegedly with over eight years of service, thousands of five-star rides, and no incidents involving female passengers. They charge Lyft with perpetuating similar bias via its “Women+ Connect” program, launched nationwide on September 11, 2023, and expanded to over 240 markets by 2025.

According to the information on the Lyft website “Women+ Connect puts women and nonbinary people in the driver’s seat – literally – by letting them choose to match with more women and nonbinary riders. The feature offers the option to turn on a preference in the Lyft app to prioritize matches with other nearby women and nonbinary riders. If no women or nonbinary riders are nearby, drivers with the preference on will still be matched with men as Women+ Connect is a preference feature, not a guarantee.”

These plaintiffs allege Lyft “has facilitated “millions” of such sex-based assignments, openly advertising the tool for enhanced “comfort” and “peace of mind” despite knowing it disadvantages the 77% male driver majority.”

The Lyft case is proposing a class of hundreds of thousands of impacted male California drivers (potentially over 80,000), they seek the same sweeping remedies: program termination through injunctions, statutory damages starting at $4,000 per violation, disgorgement of profits, punitive awards, interest, costs, and a jury trial.

Aetna Resolves SoCal Denial of Disc Surgery Class Action

A consolidated class action lawsuit has been pending in the U.S. District Court for the Central District of California for about six years. It challenged Aetna Life Insurance Company’s longstanding policy of classifying single-level lumbar artificial disc replacement (L-ADR) surgery as “experimental and investigational,” leading to systematic denials of coverage for plan members seeking this treatment for degenerative disc disease or related spinal conditions.

The consolidated action, In re Aetna Lumbar Artificial Disc Replacement Coverage Litigation, stems from two primary complaints:

– – Hendricks v. Aetna Life Insurance Co. (filed August 2019) Case No.2:19-cv-6840-AB (MAAx): A proposed class action by plaintiffs Brian Hendricks and Andrew Sagalongos, alleging systematic ERISA violations for denying L-ADR coverage to 239 class members from 2014 onward. This case was certified in June 2021 for claims under the “abuse of discretion” review standard.
– – Howard v. Aetna Life Insurance Co. (filed March 2022) Case No. 2:22-CV-01505-AB (MAAx): A separate proposed class action by plaintiff Andrew Howard, alleging similar ERISA breaches for denials under the “de novo” review standard (affecting 43 class members from 2019–2023). Certified in February 2024.

Artificial disc replacement (ADR) is newer type of spinal disc procedure that utilizes an anterior (front – through the abdominal region) approach to replace a painful, arthritic, worn-out intervertebral disc of the lumbar spine with a metal and plastic prosthesis (artificial disc). It is an alternative to traditional spinal fusion.

The suit alleged violations of the Employee Retirement Income Security Act (ERISA), claiming Aetna’s denials were arbitrary, not based on credible evidence, and inconsistent with FDA approvals (e.g., for devices like the ProDisc-L since 2006) and medical guidelines from organizations like the North American Spine Society (NASS). Plaintiffs argued this practice caused financial harm, forcing patients to pay out-of-pocket or forgo treatment.

At At the time of settlement, Aetna had produced nearly 30,000 pages of information concerning the class and merits issues in the consolidated cases. For their part, Plaintiffs produced nearly 1,500 pages of information supportive of their position that Aetna’s policies and practices are amenable to class treatment and that L-ADR is a safe and effective treatment for degenerative disc disease.

The parties participated in multiple days of mediation before Edwin Oster, Esq., an experienced and well-respected private mediator with Judicate West over a three-year period. The parties first participated in mediations and negotiations between July 2022 and April 2023. After these negotiations failed, the parties engaged in further vigorous litigation, merits discovery and expert discovery before participating in an additional mediation and arm’s-length negotiations between March 2025 and May 2025. The parties notified the Court that they reached a settlement in principle on May 16, 2025, two weeks before the final pre-trial conference and six weeks before trial. (

According to the Motion for Preliminary Approval of Class Action Settlement filed on October 8, 2025 by plaintiff attorneys, “After nearly six years of vigorous litigation, investigation, and discovery, multiple mediations, and only six weeks before the scheduled trial in this matter, Plaintiffs Brian Hendricks, Andrew Sagalongos, and Andrew Howard (collectively, “Plaintiffs” or “Class Representatives”) and Defendant Aetna Life Insurance Company (“Aetna”) agreed to settle this class action on the terms set forth in the Settlement Agreement

The Settlement provides that all Class Members who paid out-of-pocket for Single-Level L-ADR will be reimbursed up to $55,000. In addition, the Settlement provides that Class Members who have not yet the L-ADR are entitled to surgery or reimbursement for a future surgery. Class Members who are current Aetna members will be authorized for a future Single-Level L-ADR so long as their surgeon attests that the surgery is medically necessary for them, without any review by Aetna using Aetna’s own internal medically necessity criteria.

Several other major insurance companies have faced class action or ERISA-based lawsuits challenging their systematic denials of coverage for single-level lumbar artificial disc replacement (L-ADR) surgery, often labeling it as “experimental,” “investigational,” or “unproven” despite FDA approvals dating back to 2004 (e.g., for devices like the ProDisc-L). These cases mirror the Aetna litigation in alleging violations of the Employee Retirement Income Security Act (ERISA) for arbitrary denials that force patients to pay out-of-pocket or opt for less effective alternatives like spinal fusion.

As in the Aetna case, most suits have been filed in the U.S. District Court for the Central District of California, with some settlements achieved. However, coverage has improved industry-wide – now about 90% of private insurers cover single-level L-ADR, up from near-zero in the early 2000s.

Aetna revised its policy in February 2023 to cover single-level L-ADR as medically necessary under certain criteria. These suits have driven policy changes. For instance, post-settlement, UnitedHealthcare and Anthem now cover L-ADR for eligible patients, reducing denials to <10% industry-wide.

Litigation continues in a case pending in the Central District of California which was filed in 2021 against Blue Shield of California. (Torres v. California Physicians’ Service d/b/a Blue Shield of California Case No. 2:21-cv-08942-FMO-JEM filed October 29, 2021).

This suit, led by the same firm (Gianelli & Morris), alleges similar ERISA violations for BSC’s continued blanket denials of L-ADR coverage as “experimental/investigational” post-2017 settlement, particularly for patients not fitting narrow post-policy criteria or under self-funded plans. It claims BSC failed to fully implement the injunctive relief from Escalante v. California Physicians’ Service d/b/a Blue Shield of California (Case No. 2:14-cv-03021-DDP-PJW), leading to renewed harms (e.g., out-of-pocket costs exceeding $40,000 per patient).

October 27, 2025 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: DIR, Uber and Lyft Battle About Cal/OSHA Jurisdiction Over Drivers. Marin County Woman Sentenced for Insurance Fraud. Recruiters & Fraud Discovered in LA County $4B Sexual Abuse Case. DOJ and Kaiser Permanente Near Settlement of $1B Fraud Case. New Law Prohibits ‘Stay or Pay’ Employment Contracts. Congress Set to Review Another Lawsuit Abuse Reduction Act. Federal Judiciary Limiting Operations As Funding Ran Out Monday. Sutter Health Use of AI Improves Cancer Detection Rates.