The Appeals Board has issued an en banc Opinion and Order Granting State Compensation Insurance Fund's Petition for Reconsideration in Jose Dubon v. World Restoration, Inc.; State Compensation Insurance Fund, (ADJ4274323, ADJ1601669),filed and served on May 22, 2014.
According to the WCAB: "The Appeals Board granted State Compensation Insurance Fund's petition for reconsideration of the February 27, 2014 Opinion and Decision After Reconsideration (En Banc) wherein the Appeals Board previously held that the Workers' Compensation Appeals Board may determine if a utilization review decision suffered from material defects that undermine the integrity of the decision, and if so, it may then determine the medical necessity issue based on substantial medical evidence. (See Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 313 (Appeals Board en banc) (Dubon).) Reconsideration was granted in order to allow sufficient opportunity to further study the factual and legal issues, noting that the prior decision remains in effect and binding pending a decision after reconsideration in the present matter."
Therefore, until a decision issues modifying the original en banc decision in Dubon, cases may still be heard by the Appeals Board on the issue of whether the utilization review suffered from material defects that undermine the integrity of the decision, and if the utilization review decision is found invalid, the Appeals Board may determine the medical necessity issue based on substantial medical evidence"