Marissa Gonzalez-Ornelas worked for the County of Riverside and injured both of her knees while she was working as a counselor in 2004. Her physician, Dr. D’Arc, put in a request to utilization review for her to receive Synvisc injections in her knee but the request was denied. She appealed to an internal medical reviewer who also denied authorization. She appealed to the Workers’ Compensation Appeals Board (WCAB) who reversed the lower decisions and allowed her to go ahead with her treatment.

The IMR reviewer claimed there was no documentation to prove that she osteoarthritis or had tried and failed other kinds of conservative therapies or treatments for it. Her IMR appeal had been denied because the workers’ compensation judge determined there was no convincing evidence that the IMR’s initial denial was the result of a “plainly erroneous finding of fact”.

However, there was evidence to show she had osteoarthritis and had tried other treatments. Her doctor’s notes were in the IMR file. She had another physician in 2014, Dr. Jackson, who wrote that he took x-rays of her knees which showed medial compartment arthritis and patella-femoral arthritis. He diagnosed her with primary osteoarthritis in both knees and unilateral post-traumatic osteoarthritis in both knees. She had surgery in her left knee with no real improvement and when she had Synvisc injections in her knees she saw a decrease in her symptoms. He wrote that she would ultimately need both knees to be replaced, but until that time getting Synvisc injections would help relieve her symptoms. She did not do well on cortisone, and ODG recommends hyaluronic acid injections (like Synvisc) for people with osteoarthritis in the knees.

The WCAB saw this and determined that the IMR reviewer’s statements were made in error, that there was no way they should have come to the conclusion they did based on the evidence to the contrary presented in the files. They said that for the IMR reviewer to say there was no documentation that proved she had been diagnosed with arthritis and had tried other therapies for it, when it fact there was documentation that the IMR reviewer had in hand, was a “plainly erroneous express or implied finding of fact”. They reversed the findings and granted her a new IMR with a different reviewer who would apply the ODG recommendations based on her documentation.