Case Title: IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: CLAYTON STRAUBE V. THE STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION

Citation: 

Docket Number: S-08-0106

State: wyoming

Court: Wyoming Supreme Court

Date: 2009-05-20T00:00:00Z

Document:
IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: CLAYTON STRAUBE V. THE STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2009 WY 66208 P.3d 41Case Number: S-08-0106Decided: 05/20/2009
APRIL 
TERM, A.D. 2009

 
 
IN 
THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: CLAYTON 
STRAUBE,Appellant(Petitioner),v.THE STATE OF WYOMING 
ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION 
DIVISION,Appellee(Respondent).

 
 
Appeal 
from the District Court of Campbell County

The 
Honorable Michael N. Deegan, Judge

 
 

Representing 
Appellant:

Kenneth 
DeCock of Plains Law Offices LLP, Gillette, Wyoming 

 
 

Representing 
Appellee:

Bruce 
A. Salzburg, Wyoming Attorney General; John W. Renneisen, Deputy Attorney 
General; James Michael Causey, Senior Assistant Attorney General; Kristi M. 
Radosevich, Senior Assistant Attorney General

 
 
Before 
VOIGT, C.J., and GOLDEN, HILL, KITE, BURKE, JJ.

 
 
GOLDEN, 
J., delivers the opinion of the Court; BURKE, J., files a dissenting opinion, in 
which VOIGT, C.J., joins.

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Clayton Straube 
suffered an injury to his right knee while at work.  The Workers' Compensation Division 
(Division) found the injury to be compensable and awarded benefits.  Straube's knee never healed and 
approximately one year later he sought pre-authorization from the Division for 
osteochondral autograph implant surgery.  
The Division determined that Straube's current knee problems solely 
related to a preexisting condition and denied further benefits.  The Division's denial was upheld by the 
Medical Commission and, later, by the district court.  We reverse.

 
 

ISSUES

 
 
[¶2]      Straube poses 
these issues:

 
 
A.        Is 
the decision of the Medical Commission contrary to Wyoming 
law?

B.        Is 
there substantial evidence to support the [Medical Commission's] 
conclusion?

C.        Is 
the [Medical Commission's] decision arbitrary and 
capricious?

 
 

FACTS

 
 
[¶3]      On August 19, 
2005, Straube injured his right knee while working as a pipe helper for TIC 
Industrial Co., Inc. in Gillette, Wyoming.  
Straube immediately reported to the emergency room at the Campbell County 
Memorial Hospital, where he was evaluated by Dr. Nathan S. Simpson, an 
orthopedic surgeon.  Dr. Simpson 
ordered an MRI on Straube's right knee, which revealed an "osteochondral defect 
of the medial femoral condyle" and a loose fragment lodged between the anterior 
cruciate ligament (ACL) and the patellar tendon.  

 
 
[¶4]      Straube was 
referred to Powder River Orthopedics & Spine, P.C. for additional orthopedic 
consultation.  He was evaluated by 
Dr. Gerald Baker and Dr. John P. Dunn.  
Both doctors concluded:

 
 
[T]here 
does appear to be an osteochondral avulsion from the femoral condyle.  From the MRI exam, however, it is 
impossible to tell whether or not that injury is acute or chronic.  There also appears to be a loose body 
within the interchondral notch, which probably represents the loose 
osteochondral fragment.  

 
 
Dr. 
Dunn performed arthroscopic surgery on Straube's right knee on August 26, 2005, 
and removed the loose body.   
In his Operative Report, Dr. Dunn noted:

 
 
Patient 
was noted to have a large OCD lesion of the medial femoral condyle.  The remainder of the cartilage was 
pristine, and the meniscal cartilage was circumferentially stable to probing and 
pristine in appearance.  The notch 
was inspected.  The loose fragment 
of the OCD lesion was noted to be present.  
This was grasped with a pituitary and removed through a slightly enlarged 
anteromedial portal.  Next, a 
lateral compartment was inspected and found to be pristine with regards to the 
articular cartilage and the meniscus, which was stable to circumferential 
probing.  Next, an arthroscopic 
shaver was introduced.  The base of 
the OCD lesion was noted to be covered in some fibrous material, which leads me 
to believe this was a preexisting OCD lesion that merely was knocked loose when 
the patient kneeled on it.  The base 
of the OCD lesion was debrided back to bare bone with a curette.  

 
 
[¶5]      Straube received 
worker's compensation benefits for the injury and the surgery performed by Dr. 
Dunn.  In a "Final Determination 
Opening Case" issued on October 11, 2005, the Division informed Straube: 

 
 
Available 
medical evidence indicates that you suffered from a pre-existing condition 
affecting your right knee, but experienced an acute aggravation (loose body) as 
a result of the August 19, 2005, incident.  
Coverage will be provided for the acute aggravation only.  

 
 
[¶6]      After the 
surgery, Straube was provided a course of physical therapy.  In late October, Straube moved back to 
his hometown of Spokane, Washington, where he sought medical treatment with Dr. 
Thomas L. Halvorson, an orthopedic surgeon with Rockwood Clinic Orthopedics and 
Sports Medicine.  Following 
Straube's initial visit with Dr. Halvorson on December 1, 2005, Dr. Halvorson 
noted: 

 
 
PLAN:  At this point, we are going to make an 
attempt to get back to work.  I am a 
little bit doubtful that he will tolerate it; it is a fairly large lesion.  He brought his pictures with him 
today.  I suspect we are going to 
need to consider some sort of a Genzyme procedure to try to put some cartilage 
back in here.  We will go ahead and 
release him to work today, though, and see how he does.  I will plan on rechecking him once he 
has been back to work a little bit and see how he is tolerating it.  

 
 
Straube's 
knee never completely recovered, and he was unable to return to work.  Eventually, Dr. Halvorson recommended 
that Straube undergo osteochondral autograph implant surgery (also referred to 
as the "Genzyme procedure").1  

 
 
[¶7]      Dr. Halvorson 
submitted a request for preauthorization of the proposed surgical procedure to 
the Division.  After receiving the 
request, the Division sought independent medical evaluations from Dr. Meade 
Davis, III, and Dr. John A. Whipp, both board certified orthopedic 
surgeons.  The two doctors did not 
personally examine Straube and, instead, only conducted record reviews.  Dr. Davis replied to the Division as 
follows:2

 
 
I 
have reviewed the medical records which you forwarded to me on Clay 
Straube[.]  Mr Straube was injured 
on August 19, 2005, his injury consisted of squatting down and developing acute 
pain in the right knee.  He was seen 
immediately and evaluated, and then apparently a short period of time had an MRI 
which revealed a loose fragment in his knee, he underwent surgery on his right 
knee to remove the loose body and underwent a Microfracture technique[.]  The base of the defect where the 
osteochondral fragment came from was covered in fibrous material which lead Dr 
Dunn to believe there was a pre-existing osteochondritis dissecans lesion that 
was loosened by the process of squatting or kneeling.  The patient has continued to have 
symptoms, and is now being considered for further surgical 
procedure.

 
 
After 
some thought, I feel that the new requested procedure including a Genzyme 
procedure is not the responsibility of the Wyoming Worker's Safety and 
Compensation Division.  I believe 
this was a pre-existing condition which was temporarily aggravated by the simple 
process of bending the knee[.]  I 
believe the first surgery was appropriately covered by Worker's Compensation, 
however I feel that any mild activity could of caused the fragment to become 
loosened, and this could of occurred at home as well as at work with no 
particular trauma[.]  Therefore I 
feel that this follow up surgery is a result of a pre-existing condition and not 
of the acute episode that occurred at work[.]  

 
 
Similarly, 
Dr. Whipp replied:

 
 
We 
have, at your request, evaluated Mr. Straube's records[.]  It is our determination that the initial 
surgery  the arthroscopic procedure  should be paid for without 
question[.]  It is also our opinion, 
and we will say that this certainly could be questioned, assuming that someone 
feels this patient is a candidate for a Genzyme procedure, that that should not 
be paid for by the Division[.]

 
 
Our 
rationale for this is very simple.  
It is an apportionment item based upon the following facts[:] (1) Even 
though this patient was working when he sustained his injury, his injury was not 
of a nature that we believe actually caused an osteochondral fracture.  (2) It is our opinion that this was, if 
you will, a genetic predisposition that this patient had and that he probably 
already had an osteochondritis dissecans[.]  This determination by us, at least, is 
based upon the fact that (a) this came from an area where frequently dissecans 
occur, (b) he was in the right age group for this, (c) the trauma was not 
sufficient enough, in our opinion, to make this a fresh fracture, and (d) the 
operating physician thought that this was not an acute injury based upon the 
fibrous changes that he found at the base of the defect and he states this in 
the operative record.

 
 
Again, 
one certainly must consider the rule that, if someone is working and they get 
injured, it is Workers' Compensation's responsibility to care for that 
injury[.]  We think the initial 
arthroscopic procedure did so[.]  
Whether or not the Division needs to be responsible for what we would 
determine to be a very expensive and possibly still somewhat experimental 
treatment is a different matter, in our opinion.  We believe that there should be an 
apportionment rule in a case like this which we feel is fairly clearly not 
related to trauma, but to a congenital problem.  The fact that the initial surgery was 
paid for, and should have been paid for, by the Division, does not obligate the 
Division to be responsible for the entire problem.  

 
 
[¶8]      Based on the 
opinions of Dr. Davis and Dr. Whipp, the Division issued a final determination 
on September 25, 2006, denying Dr. Halvorson's request for surgical 
preauthorization.  The Division also 
issued a "Final Determination Regarding Pre-existing Condition" on September 28, 
2006, which stated in pertinent part:

 
 
Based 
upon the recent review of your surgical pre-authorization request and associated 
documentation, the Division has determined that your current condition and 
related treatment is not compensable.

 
 
Available 
medical evidence indicates that the injury you sustained while in the course of 
employment with TIC was an acute aggravation of a pre-existing condition.  (See enclosed Final Determination dated 
October 11, 2005[.])  The treatment 
for the temporary aggravation has been appropriately compensated by the 
Division; and medical evidence clearly indicates that any further medical 
intervention after December 1, 2005, is due solely to your pre-existing 
condition and in no way related to the August 19, 2005, incident.  (Wyoming Statute 27-14-102(xi) & 
27-14-102(xii)[.])  

 
 
[¶9]      Straube objected 
to the Division's decisions, and his case was referred to the Medical Commission 
for an administrative hearing.  
While the hearing was pending, Straube moved back to Gillette and, once 
again, sought treatment with Dr. Dunn.  
In his medical records dated November 10, 2006, Dr. Dunn noted that 
Straube continues to have pain and that he is

 
 
being 
evaluated by another orthopedic surgeon for Carticel autologous chondrocyte 
transplant.  We discussed this 
procedure with the patient.  I 
believe he is a good candidate for this.  
Unfortunately, it is not a procedure that I perform here in Gillette, 
Wyoming.  The question has risen as 
to whether this is a preexisting condition or not.  I believe that the OCD lesion may have 
been preexisting, but it is almost certainly significantly aggravated and 
exacerbated by his work injury there.  
Patient is going to pursue the Carticel transplantation, and I am going 
to see him back on an as needed basis.   

 
 
On 
July 16, 2007, Dr. Dunn provided a letter to Straube's counsel, which stated in 
relevant part:

 
 
It 
is my opinion, based on surgical findings, that the OCD lesion likely did, 
indeed, predate his Workers [sic] Compensation injury.  However, the work related injury did 
result in the detachment of the OCD lesion, requiring the initial surgery.  Unfortunately, the patient has had 
continued pain and problems and has an articular cartilage defect in the knee, 
which could be potentially aided by the proposed Genzyme 
procedure.

 
 
As 
to your question, "Had the detachment not occurred, would Mr. Straub [sic] 
require this procedure?" the answer is no.

 
 
[¶10]   At the contested case hearing held 
on August 8, 2007, the Medical Commission hearing panel was presented with the 
medical records, the letters authored by Dr. Dunn, Dr. Davis and Dr. Whipp, and 
Straube's testimony.  Straube 
indicated that he made an attempt to return to light-duty work after his initial 
surgery but was very limited in what he could do.  Straube testified his knee has not 
significantly improved since the surgery; he continues to experience constant 
pain and that his physical activities, including walking, are severely 
limited.  Straube also testified 
that he never had any physical problems with his knee before the August 19 work 
injury.  

 
 
[¶11]   By order dated September 19, 2007, 
the Medical Commission upheld the Division's denial of benefits.  In its Findings of Fact, the Medical 
Commission stated:

 
 
9.         
. . . This Panel disagrees with Dr. Dunn's opinion, and finds that the 
respective opinions of Drs. Davis and Whipp are more persuasive.  Clearly, Mr. Straube had a preexisting 
condition, which we find to be significant.  The osteochondral defect has been 
variously described as very large and substantial, and Dr. Dunn identified early 
on in his initial surgical procedure that the defect was likely 
preexisting.  We also note that the 
mechanism of the work injury was relatively minor with the Employee/Claimant 
simply kneeling and the loose body created by the osteochondral defect having 
broken free at that point in time.

 
 
This 
Panel finds that the preexisting osteochondral defect is the primary reason for 
the Employee/Claimant's present need for the surgical repair to his knee, and 
Mr. Straube would have certainly required surgical intervention at some time, 
due to the significant nature of the defect.  Certainly such a kneeling incident could 
have occurred virtually anywhere, and there is little connection with the nature 
of the injury and the overall duties of his job, where he had only been employed 
for three days.

 
 
10.       . . . the 
Division met its obligation to Mr. Straube for the work injury by providing him 
with a contemporaneous surgery that removed the loose body fragment that was 
occasioned by the incident at work.  
Such an approach was medically reasonable at the time.  Unfortunately, Mr. Straube continues to 
have significant issues with his knee, but this Panel finds that those 
complaints are entirely related to the preexisting condition and not the 
creation of the loose body, which was caused by the work injury.  Mr. Straube, regardless of the existence 
of the work injury, was clearly in a situation where he would at some point 
require surgical intervention to his knee because of the preexisting 
osteochondral defect.  

 
 
The 
Medical Commission concluded:

 
 
7.         
. . . Although apportionment could be easily accomplished in this case 
due to the discrete nature of the work injury and the preexisting condition, 
such an approach is not permitted under the present regulatory and statutory 
scheme.  This Panel therefore finds 
that the need for a subsequent surgery is not directly and causally related to 
the work injury, but rather is caused solely by the significant preexisting 
osteochondral defect, which preceded Mr. Straube's work 
injury.

 
 
. 
. . Mr. Straube's medical situation and the need for medical care and treatment 
can easily be separated out into that which was caused by the workplace injury, 
and that which was not, and was primarily due to his preexisting condition.  Mr. Straube was initially surgically 
treated by Dr. Dunn, and the removal of the loose body by Dr. Dunn was 
necessitated by the work injury.  
The need for subsequent surgery, however, can be solely attributed to the 
preexisting condition of the osteochondral defect.  Drs. Davis and Whipp both opined that 
the need for the subsequent surgery was not related to the original work 
injury.  

 
 
*  *  
*  *

 
 
11.       . . . This 
Panel finds and concludes that the Workers' Safety and Compensation Division has 
met its obligation to Mr. Straube in providing medical care and treatment and 
the initial surgical procedure for the specific work-related injury.  The loose body became detached while he 
was working and the Division paid for the medical care to remove that loose 
body.  Mr. Straube clearly needs 
additional care and treatment for the osteochondral defect.  Additional care and treatment, however, 
is primarily due to the significant preexisting condition that predated the work 
injury and not because he happened to dislodge the loose body while he was at 
work.  This Panel finds that the 
Employee/Claimant has not met his burden in establishing that there is a causal 
connection between his current condition and the work injury of August 19, 
2005.  

 
 
[¶12]   On review, the district court 
affirmed the denial of benefits.  
This appeal followed.

 
 

STANDARD 
OF REVIEW

 
 
[¶13]   On appeal from a district court's 
review of an administrative agency's decision, we afford no deference to the 
district court's decision.  Rather, 
we review the case as if it came directly from the agency.  Dale v. S & S Builders, LLC,  2008 WY 84, ¶ 8, 188 P.3d 554, 557 (Wyo. 
2008); McIntosh v. State ex rel. Wyoming 
Medical Comm'n, 2007 WY 108, ¶ 8, 162 P.3d 483, 487 (Wyo. 2007).  As in all administrative proceedings, 
the scope of our review is governed by the factors specified in Wyo. Stat. Ann. 
§ 16-3-114(c) (LexisNexis 2007), which provides in pertinent 
part:

 
 
(c)  To the extent necessary to make a 
decision and when presented, the reviewing court shall decide all relevant 
questions of law, interpret constitutional and statutory provisions, and 
determine the meaning or applicability of the terms of an agency action. In 
making the following determinations, the court shall review the whole record or 
those parts of it cited by a party and due account shall be taken of the rule of 
prejudicial error. The reviewing court shall: 

 
 
                                    
*  *  *  
*

 
 
(ii)  Hold unlawful and set aside agency 
action, findings and conclusions found to be: 

            
(A)  Arbitrary, capricious, 
an abuse of discretion or otherwise not in accordance with law; 
 

(B)  Contrary to constitutional right, power, 
privilege or immunity;  

(C)  In excess of statutory jurisdiction, 
authority or limitations or lacking statutory right; 
 

(D)  Without observance of procedure required 
by law; or  

(E)  Unsupported by substantial evidence in a 
case reviewed on the record of an agency hearing provided by 
statute.

 
 
[¶14]   We discussed in detail the proper 
application of these standards in Dale, ¶¶ 20-26, 188 P.3d  at 560-62.  In short, we defer to an agency's 
findings of fact if supported by substantial evidence.  Id., ¶ 22, 188 P.3d  at 561.  We will not substitute our judgment for 
that of the agency if the agency's decision is reasonable under the 
circumstances.  Id.  We review an agency's finding that the 
burdened party failed to prove all the elements of his claim, as in this case, 
to determine "whether that conclusion was contrary to the overwhelming weight of 
the evidence in the record as a whole."  
Id.; see also Langberg v. State ex rel. Wyoming 
Workers' Safety & Comp. Div., 2009 WY 39, ¶ 10, 203 P.3d 1098, 1101 
(Wyo. 2009); Horn-Dalton v. State ex rel. 
Wyoming Workers' Safety & Comp. Div., 2009 WY 14, ¶ 7, 200 P.3d 810, 813 
(Wyo. 2009).  As always, we review 
an agency's conclusions of law de novo.  
Dale, ¶ 26, 188 P.3d  at 
561.

 
 

DISCUSSION

 
 
[¶15]   The principles governing a 
claimant's burden of proof are well established:

 
 

In 
order to be eligible to receive worker's compensation benefits, a claimant must 
have sustained an "injury" as defined by Wyo. Stat. Ann. § 27-14-102(a)(xi) 
(LexisNexis 2001).  "Injury'" means 
any harmful change in the human organism other than normal aging . . . arising 
out of and in the course of employment while at work. . . ."  To demonstrate that an injury arose out 
of the course of employment, the claimant must establish a causal connection 
between the work-related incident and the injury.  Hanks v. City of Casper, 2001 WY 
4, ¶ 6, 16 P.3d 710, 711 (Wyo. 2001).  
The claimant bears the burden of proving this causal connection by a 
preponderance of the evidence.  
Clark v. State ex rel. Wyoming Workers' Safety and Compensation 
Div., 2001 WY 132, ¶ 19, 36 P.3d 1145, 1150 (Wyo. 2001).  "A preponderance of the evidence' is 
defined as proof which leads the trier of fact to find that the existence of 
the contested fact is more probable than its non-existence.'"  Matter of Worker's Compensation Claim 
of Thornberg, 913 P.2d 863, 866 (Wyo. 1996) (quoting Scherling v. 
Kilgore, 599 P.2d 1352, 1359 (Wyo. 1979)).

 
 

Anastos 
v. General Chemical Soda Ash, 
2005 WY 122, ¶ 20, 120 P.3d 658, 665-66 (Wyo. 
2005).

"Injury," 
as the term is defined in Wyo. Stat. Ann. § 27-14-102(a)(xi) (LexisNexis 2003) 
of the Wyoming Workers' Compensation Act, does not include any injury or 
condition preexisting at the time employment begins with the employer against 
whom a claim is made.  However, "in 
Wyoming an employer takes the employee as he finds him."  Lindbloom v. Teton International, 
684 P.2d 1388, 1389 (Wyo. 1984).  If 
an employee suffers from a preexisting condition, that employee may still 
recover if his employment substantially or materially aggravates that 
condition.  Id.  In Lindbloom, we cited with approval the widely 
accepted treatise, Larson's Workmen's Compensation Law, for the proposition 
that:

 
 

Preexisting 
disease or infirmity of the employee does not disqualify a claim under the 
"arising out of employment" requirement if the employment aggravated, 
accelerated, or combined with the disease or infirmity to produce the death or 
disability for which compensation is sought.

 
 
1 
Larson's Workmen's Compensation Law, § 12.20, p. 273-276.  Larson goes on to 
say:

 
 
            
Since the rule of law stated at the beginning of this section is so 
widely accepted, in practice most of the problems in this area are medical 
rather than legal.  * * * * It will 
be found, then, that denials of compensation in this category are almost 
entirely the result of holdings that the evidence did not support a finding that 
the employment contributed to the final result.  Whether the employment aggravated, 
accelerated, or combined with the internal weakness or disease to produce the 
disability is a question of fact, not law, and a finding of fact on this point * 
* * * based on any medical testimony * * * * will not be disturbed on 
appeal.

 
 

Id., 
§ 12.20, p. 313-16.

 
 

Boyce 
v. State ex rel. Wyoming Workers' Safety & Comp. 
Div., 
2005 WY 9, ¶ 10, 105 P.3d 451, 454-55 (Wyo. 
2005).

 
 
Expert 
opinion testimony ordinarily will be required to establish the link between the 
employee's work activity or injury and the preexisting disease or condition; the 
expert need not state with specificity that the work activities or injury 
materially or substantially aggravated, accelerated, or combined with the 
preexisting disease or condition to necessitate the medical treatment for which 
compensation is sought; and the expert need not apportion between the work 
activity or injury and the preexisting disease or condition; the relative 
contribution of the work activity or injury and the preexisting disease or 
condition is not weighed.

 
 

Ramos 
v. State ex rel. Wyoming Workers' Safety & Comp. Div., 
2007 WY 85, ¶ 18, 158 P.3d 670, 677 (Wyo. 2007) (citing Boyce, ¶¶ 11, 16, 105 P.3d at 
455-56).

 
 
[¶16]   With these principles in mind, we 
now turn to Straube's complaints.  
We find it expedient to identify the focus of our analysis.  It is undisputed that Straube suffers 
from a preexisting condition.  It is 
also undisputed that Straube suffered a compensable material aggravation of this 
preexisting condition.  Straube's 
first surgery on August 26, 2005, was covered as being directly necessitated by 
the work injury.  The question 
before us is therefore whether the need for the proposed second surgery is also 
causally related to Straube's work injury.

 
 
[¶17]   In support of its decision to deny 
benefits, the Medical Commission relied on the reports from Dr. Davis and Dr. 
Whipp.  The opinions of these 
doctors are not based so much on medical information as their individual 
thoughts on the state of the law.3  Dr. Davis stated that he thought about 
the situation and, since the initial injury could have occurred at anytime, the 
consequences of the surgery should not be the responsibility of the 
Division.  The injury did not, of 
course, happen at just anytime, it happened while Straube was on the job.  As already noted, an employer takes an 
employee as he finds him. Lindbloom, 684 P.2d  at 1389.  The Division recognized this rule when 
it initially granted benefits for a material aggravation.  Because benefits were granted for the 
consequences of the injury, anything that is a direct continuing consequence is 
also covered.  Dr. Whipp discussed 
apportionment.  So did the Medical 
Commission.  The Medical 
Commission's ultimate conclusion was, since apportionment under these 
circumstances is not legally allowed, then no benefits should be 
granted.

 
 
[¶18]   Needless to say, it is not for 
doctors or the Medical Commission to question public policy, let alone thwart 
it.  The inability to apportion the 
medical consequences of a work injury between the immediate injury and a 
preexisting condition is not a reason to deny benefits.  Benefits are awarded if the medical 
consequences are causally related to the work injury.  The evidence in this case supports such 
causal connection.  Straube's knee 
never fully recovered after the work injury, as evidenced by the continued 
weakness in the knee and Straube's continued pain.4  More importantly, the only medical 
evidence directly on point comes from Dr. Dunn, who unequivocally stated the 
currently recommended surgery would not be necessary had it not been for the 
work injury.  We must, therefore, 
conclude that the decision of the Medical Commission is against the overwhelming 
weight of the evidence.

 
 
[¶19]   The decision of the Medical 
Commission is reversed.  This case 
is remanded to the district court to reverse the order denying benefits and for 
entry of an order granting benefits.

 
 
FOOTNOTES

 
 

1Under this procedure, a small amount of cartilage is taken from the 
patient's knee.  This sample is sent 
to a lab, where it is cultured and grown into a larger sample, which is later 
implanted into the patient's knee.  

 
 

2We have chosen not to correct all of the obvious punctuation and 
grammatical errors.

 
 

3We note that the doctors' responsive reports fail to identify the medical 
records they reviewed.

 
 

4Straube's continuing symptoms are even recognized by Dr. Davis and the 
Medical Commission.

 
 

BURKE, 
Justice, dissenting, with whom VOIGT, Chief Justice, 
joins.

[¶20]   I respectfully 
dissent.

 
 
[¶21]   Mr. Straube injured his right knee 
while at work.   During 
surgery, paid for by workers' compensation, a loose fragment of bone or 
cartilage was removed from the knee joint.  
The surgeon's notes indicated that Mr. Straube had a "preexisting . 
. . lesion that merely was knocked loose when the patient kneeled on it."  Later, Mr. Straube's doctor recommended 
a second surgical procedure to repair cartilage in the knee.  The basic issue before the Medical 
Commission was whether the second surgery was necessary because of the 
pre-existing condition, or whether the work-related injury had caused or 
materially aggravated the pre-existing condition.  As the Medical Commission correctly set 
forth in its decision, pre-existing conditions are generally not 
compensable.  Workers' compensation 
benefits are proper, however, if the "work effort contributed to a material 
degree to the precipitation, aggravation or acceleration of the existing 
condition of the employee."  Haynes v. State ex rel. Wyoming Workers' 
Comp. Div., 962 P.2d 876, 878 (Wyo. 1998). 

 
 
[¶22]   After a hearing, the Medical 
Commission found that the recommended surgery was attributable to the 
pre-existing condition, not the work-related injury.  "We defer to an agency's findings of 
fact if supported by substantial evidence upon the record as a whole."  Langberg v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2009 WY 39, ¶ 10, 203 P.3d 1098, 1101 (Wyo. 
2009), citing Dale, ¶ 22-26, 188 P.3d  at 561-62.  The basic question 
before us on appeal, then, is whether there is substantial evidence in the 
record to support the Medical Commission's findings.  There is.     

 
 
[¶23]   Reports from Drs. Davis and Whipp 
stated that the condition was pre-existing, and indicated that it was not caused 
or materially aggravated by the work-related injury.  The majority observes that these two 
doctors' opinions were based not "so much on medical information as their 
individual thoughts on the state of the law."  Stripped to basics, however, 
Dr. Davis's report set forth his medical opinion that Mr. Straube's 
"follow up surgery is a result of a pre-existing condition and not of the acute 
episode that occurred at work."  
Dr. Whipp's report related his medical opinion that 
Mr. Straube's work-related injury "was not of a nature that we believe 
actually caused" the underlying condition, which was "a genetic predisposition 
that this patient had and that he probably already had."  These opinions provided substantial 
evidence to support the Medical Commission's findings. 

 
 
[¶24]   Contrary evidence was provided by 
Dr. Dunn.  He agreed that 
Mr. Straube had a pre-existing condition, but opined that further treatment 
would not have been necessary except for the work-related injury.  The Medical Commission weighed the 
conflicting evidence, and made its position clear:  "This Panel disagrees with 
Dr. Dunn's opinion, and finds that the respective opinions of 
Drs. Davis and Whipp are more persuasive."  On that basis, the Medical Commission 
found that Mr. Straube's second surgery was necessary because of his 
pre-existing condition, and not because of his work-related 
injury.

 
 
[¶25]   The majority seems to discount the 
opinions of Drs. Davis and Whipp because they reviewed Mr. Straube's medical 
records but did not examine the patient.  
This is common enough in workers' compensation cases, and does not render 
the evidence inadmissible or incompetent.  
It may affect the credibility or persuasiveness of the doctors' opinions, 
but it is up to the Medical Commission, not this Court, to determine the 
credibility of witnesses and the weight afforded to conflicting evidence.  "[W]e defer to the experience and 
expertise of the agency in its weighing of the evidence."  Southwest Wyoming Rehabilitation Center v. 
Employment Sec. Comm'n of Wyoming, 781 P.2d 918, 921 (Wyo. 1989).  Deference is particularly appropriate 
here, as the Medical Commission was established specifically as "a means for 
parties to have difficult medically contested issues such as these resolved by a 
panel of the medical commission, which is comprised of health care providers 
with the professional expertise to make an informed decision."  Snyder v. State ex rel. Wyoming Worker's 
Compensation Div., 957 P.2d 289, 294 n.2 (Wyo. 1998).  

 
 
[¶26]   I would defer to the Medical 
Commission's findings of fact, and affirm its decision.