Hamilton vs. State Compensation Insurance Fund (2004) 32 CWCR 249 WCAB Panel Decision:

Hamilton was the first citable WCAB opinion that stated the insurer’s UR department had erred by using the ACOEM guidelines to deny recommended treatment for a patient who was suffering chronic pain. Workers’ Compensation Administrative Law Judge (“WCJ”) Webber relied on (and quoted) the forthcoming ACOEM verbiage to support his opinion:

“ Recommendations on assessing and treating adults with potentially work-related low back problems (i.e., activity limitations due to symptoms in the low back of less than three months duration) are presented in this clinical practice guideline…. this chapters master algorithm schematizes how primary care and occupational medicine practitioners generally can manage acute or subacute low back complaints.”

Based upon this verbiage, WCJ Webber opined:

“The ACOEM guidelines themselves, in the opinion of this WCJ, clearly provide for applicability only during the first 90 days following the industrial injury."

His decision was appealed to the WCAB by the insurer; however, the assigned three commissioner panel agreed with WCJ Webber’s opinion on ACOEM and denied the insurers request for reconsideration (appeal).