KATHLEEN CZARNECKI, Applicant,
v.
GOLDEN EAGLE INSURANCE CO., Permissibly Self-Insured, Defendant.
Nos. SDO 0217617, SDO 0217759
California Workers Compensation Decisions
Workers’ Compensation Appeals Board State Of California
March 26, 1998
OPINION
AND DECISION AFTER RECONSIDERATION
Robert
N. Ruqqles
On May
26, 1998, reconsideration was granted in this matter to
provide an opportunity to further study the legal and factual
issues raised by the petition for reconsideration. Having
completed our review, we now issue our Decision After
Reconsideration.
Defendant,
Golden Eagle Insurance Company, seeks reconsideration of the
Findings and Award, issued March 6, 1998, in which a
workers' compensation referee (WCR), following an
expedited hearing, ordered defendant to provide applicant,
Kathleen Czarnecki, the medical treatment recommended by her
treating physician, Dr. James McClurg.
Defendant
contends that the finding that applicant is in need of the
medical treatment recommended by Dr. McClurg is not supported
by the evidence, and argues that the WCR erred in excluding
its medical evidence from the record.
The
issue presented is whether medical reports obtained pursuant
to the Utilization Review standards promulgated by the
Administrative Director of the Division of Workers'
Compensation are admissible as evidence to determine the
appropriateness of a recommended medical procedure.
Following
our review of the record, and for the reasons set forth
below, we shall affirm the WCR's determination and deny
the defendant's Petition for Reconsideration.
Applicant
sustained an admitted injury to her neck, right shoulder and
right upper extremity on March 4, 1996 and over the
cumulative period ending March 4, 1996, while employed as a
claims examiner.
In a
January 13, 1997 report, applicant's treating physician,
Dr. McClurg, requested authorization from defendant to
perform arthroscopic surgery on applicant's right
shoulder. On March 25, 1997, applicant filed a request for an
expedited hearing, citing defendant's failure to respond
to Dr. McClurg's recommendation.
When
the matter came on for hearing on June 30, 1997, the parties
had reached a stipulation authorizing Dr. McClurg to proceed
with his recommended right shoulder arthroscopic
acromioplasty and Mumford procedure.
On
October 15, 1997, Dr. McClurg sought authorization to perform
a second surgery, an open Mumford's procedure, on
applicant's shoulder.
On
December 1, 1997, applicant again sought an expedited
hearing, based upon defendant's refusal to authorize this
second surgical procedure recommended by Dr. McClurg. The
matter was heard on January 26, 1998.
Applicant
submitted four reports by Dr. McClurg, in which he set forth
the basis for his recommendation for a second arthroscopic
surgery on applicant's right shoulder, and in which he
responded to the objections received from defendant's
non-examining physicians at Physician Authorization Review,
Inc.
Dr.
McClurg states at page 2 of his November 24, 1997
supplemental report:
Ms. Czarnecki has well established focal tenderness to the
acromioclavicular joint. This has been acknowledged by the
independent evaluation of Dr. Schultz which was [a] totally
independent and free opinion sought directly by the patient.
X-rays show a good subacromial decompression anteriorly, and
a residual spike on the acromioclavicular joint. It is very
difficult to
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