Case Title: Tenny v. Loomis Armored US, LLC

Citation: 

Docket Number: 48100

State: idaho

Court: Idaho Supreme Court (civil)

Date: 2021-06-22T00:00:00Z

Document:
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IN THE SUPREME COURT OF THE STATE OF IDAHO 
Docket No. 48100 
 
STEVE R. TENNY, 
 
     Claimant-Respondent, 
 
v. 
 
LOOMIS ARMORED US, LLC, Employer; 
and ACE AMERICAN INSURANCE CO., 
Surety, 
 
     Defendants-Appellants. 
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Boise, May 2021 Term 
 
Opinion Filed: June 22, 2021 
 
Melanie Gagnepain, Clerk 
 
Appeal from the Industrial Commission of the State of Idaho.  
 
The decision of the Industrial Commission is affirmed. 
 
Hawley Troxell, Boise, for appellant, Loomis Armored US, LLC. Mindy M. Muller 
argued.  
 
Monroe Law Office, Boise, for respondent, Steve R. Tenny. Darin G. Monroe 
argued.  
 
_____________________ 
 
STEGNER, Justice. 
This is an appeal from a decision of the Idaho Industrial Commission. In December 2014, 
Steve Tenny (Tenny) sustained a right-sided lumbar disc herniation injury during the course of his 
employment with Loomis Armored US (Loomis). He immediately began treatment, receiving a 
series of right-sided steroid injections in his back at L3-4. At some point shortly after the second 
injection, Tenny began to complain of increasing left hip and groin pain and underwent testing and 
treatment for these symptoms. However, the worker’s compensation insurance surety, Ace 
American Insurance Co., ultimately denied payment for treatment related to the left-side groin 
pain. Following the matter going to hearing, the Referee recommended that the Industrial 
Commission find that the left-sided symptoms were causally related to Tenny’s December 2014 
industrial accident. The Industrial Commission adopted the Referee’s findings, and after 
unsuccessfully moving for reconsideration, the employer and surety (which will be jointly referred 
to as the Defendants) appealed to this Court. At issue is the question of causation: Was the left-
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side groin pain experienced by Tenny causally related to his industrial accident? For the reasons 
set out below, we affirm the decision of the Industrial Commission. 
I. 
FACTUAL AND PROCEDURAL BACKGROUND 
A. Factual Background 
Tenny worked for Loomis as a driver, also known as an “armored service technician” 
(AST). On December 2, 2014, Tenny was pushing a pallet loaded with ore when he felt “a sharp 
shock” in his lower back. Within a few hours his pain and discomfort increased, and he presented 
at an urgent care facility with symptoms of radiating pain down his right leg to his toes. Tenny 
was referred for an MRI of his lumbar spine, which revealed that he had a right asymmetric disc 
extrusion at L3-4, with moderate to severe stenosis. In other words, Tenny had a disc herniation 
on the right side with moderate to severe narrowing of the spinal canal. 
On December 22, 2014, Tenny received a right-sided epidural steroid injection (ESI) at 
L3-4. On January 8, 2015, Tenny received a second ESI in the same location. However, after the 
second injection, Tenny began to experience pain and discomfort in his left hip and groin. 
According to Tenny and his wife, this pain began immediately during the injection, while the 
handwritten notations on a diagnostic “block sheet” indicate that his left hip pain “[b]ecame very 
uncomfortable a few hours” after the injection. Tenny later testified that he told the individual 
performing the injection that he felt “pain in the deep part of” his left groin, but that he was told 
“it was impossible” because they were not injecting that area. When Tenny’s wife testified, she 
corroborated Tenny’s testimony that he had told her about the left-sided pain immediately after 
the injection, although she was not present during the injection. 
Tenny’s pain levels in his left groin increased in intensity over the next few days, and 
several weeks after the second injection he was referred to a neurological surgeon, Dr. Michael 
Hajjar. Dr. Hajjar ordered a new lumbar MRI, which was consistent with the prior scans. Dr. Hajjar 
then sent Tenny for a bilateral lower extremity nerve conduction study, which found normal results 
without any obvious neurological or neuropathic issues. Seeking to rule out this pain’s relation to 
Tenny’s previous left hip replacement which he underwent in January 2014, Dr. Hajjar advised 
Tenny to visit his prior surgeon, Dr. Roman Schwartsman. Tenny was referred by Dr. 
Schwartsman for x-rays of the hip and pelvis. Upon review of those images, Dr. Schwartsman 
concluded that the left hip replacement was not the cause of Tenny’s pain. 
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Dr. Hajjar recommended back surgery, which Tenny underwent on April 6, 2015. Although 
Tenny’s disc herniation was on the right side, Dr. Hajjar performed a bilateral surgery at L3-4, 
which included a microdiscectomy and decompression. As Tenny recovered from the surgery, he 
found that his right-sided back pain had resolved; however, the left hip and groin pain had not. 
Tenny underwent a CT scan of the pelvis, showing no pathological findings in the left-sided 
musculature. 
Dr. Hajjar concluded that the back symptoms had resolved; however, because of the 
lingering left-sided groin and hip pain, he suggested pain management, and referred Tenny to Dr. 
Christian Gussner, a physician focused on physical medicine and pain medicine. 
Dr. Gussner identified several possible sources for the incessant left-sided hip and groin 
pain, including an inguinal hernia, bursitis of the hip, or something related to Tenny’s recent 
surgery. Dr. Gussner referred Tenny to a specialist for evaluation of a possible hernia. 
On September 2, 2015, Dr. Gussner gave Tenny two steroid injections into the bursae of 
his left hip, but Tenny reported no relief in either injected area. By this time, Tenny had been 
evaluated by a specialist for a possible hernia, but no hernia was found. Suspecting that the pain 
was related to the prior left hip replacement or to opioid-induced hyperalgesia,1 Dr. Gussner 
referred Tenny back to Dr. Schwartsman and advised Tenny to taper off opioid medication. 
Tenny again visited Dr. Schwartsman. Dr. Schwartsman ordered a repeat MRI of the 
lumbar area to look for L3-4 pathology that would explain his symptoms. He also referred Tenny 
to a neurosurgeon, Dr. R. Tyler Frizzell. 
On October 6, 2015, Tenny visited Dr. Frizzell for the first time. Dr. Frizzell ordered an 
intrathecal lumbar CT, but its results did not reveal anything that would account for Tenny’s 
symptoms. Dr. Frizzell noted that Tenny’s pain “may be related to some of the peripheral nerves 
innervating” the left groin. At this point, Dr. Frizzell referred Tenny to Dr. Sandra Thompson for 
further evaluation and pain management. 
Tenny visited Dr. Thompson at The Pain Center for the first time in November 2015, and 
would continue to be treated by her for several years. Dr. Thompson took several approaches to 
managing Tenny’s pain, including oral medication and transdermal medication. When these 
methods failed to work, Dr. Thompson referred Tenny to Dr. Calhoun, a psychiatrist, to determine 
                                                 
1 Opioid-induced hyperalgesia is a condition experienced by some chronic users of opioids, where their perception of 
pain is actually increased by their use of opioids. 
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if Tenny was a candidate for a pain pump, a surgically implanted dispenser that delivers pain 
medication straight to the spinal fluid.2 In April 2016, Tenny underwent a trial with an intrathecal 
pain pump. As a result of that procedure, a permanent intrathecal pain pump was placed two weeks 
later. Both Dr. Thompson and Tenny testified that the pain pump stabilized his pain levels without 
the adverse side effects accompanying oral or topical pain medication, although the left-sided groin 
pain has never resolved. 
In December 2016, Tenny underwent an independent medical examination (IME) with Dr. 
Rodde Cox. Dr. Cox noted that it would be reasonable to order an MRI of the pelvis “to evaluate 
for any soft tissue structures that could be contributing such as an iliopsoas bursa.” Dr. Cox’s 
conclusion at that time was that “to a reasonable degree of medical certainty, there is causal 
relationship between [Tenny’s] back and leg complaints and the reported injury” on the job. 
On January 4, 2017, an MRI of the pelvis without contrast was performed. This MRI 
revealed “small to moderate left iliopsoas bursitis.” Dr. Cox subsequently amended his IME to 
reflect that his medical opinion was that Tenny’s pain was caused by left-sided bursitis, which was 
not caused by Tenny’s December 2014 injury. 
Although the Surety initially paid for Tenny’s treatment, after Dr. Cox’s IME was updated, 
the Surety concluded that Tenny was at maximum medical improvement and denied the remainder 
of his claim for medical treatment related to the left-sided hip pain. The Surety contended that 
Tenny’s left-sided hip pain was not related to his on-the-job injury. 
B. Procedural History 
On January 16, 2019, a hearing was conducted by Industrial Commission Referee Powers. 
The parties also submitted post-hearing briefs and conducted post-hearing depositions of Tenny’s 
treating doctors. Referee Powers retired before a recommendation was issued and he was replaced 
by Referee Harper pursuant to a stipulation of the parties. Referee Harper considered the evidence 
submitted and rendered a recommended disposition. In sum, Referee Harper considered the 
depositions of 
1. Tenny, taken April 13, 2017; 
2. Dr. Cox, taken March 12, 2019; 
3. Dr. Frizzell, taken February 28, 2019; 
4. Dr. Gussner, taken March 11, 2019; 
                                                 
2 This evaluation was deemed necessary considering Tenny’s pre-existing risk factors for drug dependence.  
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5. Dr. Hajjar, taken March 14, 2019; and 
6. Dr. Thompson, taken March 6, 2019. 
Referee Harper also considered the testimony of Tenny, his wife Kristi, and Tenny’s nurse case 
manager which was elicited at the hearing. Additionally, Referee Harper considered the exhibits 
consisting of Tenny’s treatment records. Finally, Referee Harper considered Claimant’s Exhibit 
A, which consisted of the case manager’s notes. 
Referee Harper characterized “[t]he question for resolution” as “whether [Tenny’s] 
ongoing left-sided hip/groin pain is causally related to his industrial accident, including whether it 
is a compensable consequence of medical treatment provided to him for his accepted work injury.” 
Referee Harper summarized the evidence presented, first noting that Dr. Frizzell and Dr. 
Thompson had provided medical opinions as to causation that were favorable to Tenny, i.e., that 
the second ESI caused nerve root dysfunction that resulted in pain into the left groin region. Dr. 
Frizzell’s opinion focused on the potential for L3-4 radiculopathy to correspond with nerve pain 
in the groin area. Dr. Thompson opined that if bursitis were the primary cause of Tenny’s pain, it 
would have been effectively addressed by anti-inflammatories, but this course of treatment had 
not worked for Tenny. Dr. Thompson admitted that there was no objective evidence to show the 
root of Tenny’s pain but opined that “something happened” at this ESI to precipitate his pain, to a 
“highly likely” degree.  
Referee Harper also noted that Dr. Schwartsman, Dr. Krafft, Dr. Hajjar, and Dr. Gussner 
provided opinions on causation favorable to the Defendants. Dr. Schwartsman provided a 
summary opinion letter from April 2017, after Tenny’s second MRI of the pelvis, and agreed with 
the IME that the cause of Tenny’s pain was likely the iliopsoas bursitis. Dr. Krafft, who conducted 
Tenny’s initial nerve tests, opined that for the ESI to have caused Tenny’s groin pain, the injecting 
doctor “would have had to miss by two levels to hit a nerve that would impact the groin because 
the groin is not in the nerve distribution for the L3-4.” Dr. Hajjar’s opinion noted that nerve damage 
caused by an injection would be immediate, rather than gradual, and noted that Tenny’s subsequent 
nerve tests did not show any denervation that would be expected if there was nerve damage years 
previously. Dr. Hajjar admitted that bursitis could be discovered through a CT scan, ultrasound, 
or MRI, and that all scans prior to the January 2017 MRI of the pelvis did not reveal any bursitis. 
Dr. Gussner opined that Tenny’s pain was most likely caused by the iliopsoas bursitis. Dr. 
Gussner suggested that Tenny could have had tight hip flexors as a result of his prior left hip 
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replacement, and that lying in a prone position could have stretched the hip flexors, contributing 
to the bursitis. He admitted that he had ruled out bursitis when he gave Tenny two steroid injections 
in the bursae, but stated simply that he could have missed the bursae, as he did not use an ultrasound 
guided injection process but rather palpated Tenny and injected the tenderest spots. Dr. Gussner 
testified that the MRI was the only objective test imaging study explaining the location of Tenny’s 
pain. He offered no explanation for why it had not been evident in any of the imaging that had 
been done before January 2017. 
Finally, Dr. Cox provided testimony, in addition to his IME, that bursitis was the most 
likely cause of Tenny’s pain. He noted that Tenny’s pain worsened over time, rather than 
improving, and stated that nerve damage pain would be immediate, not gradual. He also admitted 
that Tenny’s pain levels were high but suggested that this would be consistent with a somatic 
system disorder.  
Referee Harper rejected the Defendants’ argument that it was impossible to damage nerves 
affecting the groin with an L3-4 injection, noting that several doctors and a medical journal article 
established that it was possible for the L3 nerve root to innervate the area of Tenny’s pain. While 
Referee Harper noted that neither Dr. Frizzell nor Dr. Thompson explicitly opined that the second 
ESI had impacted the left-sided nerves innervating Tenny’s left groin, they did implicitly support 
that conclusion. Finally, Referee Harper reasoned that the “most compelling evidence in favor of 
causation” was the temporal relationship between the ESI and Tenny’s symptoms, along with 
Tenny’s testimony of a conversation with the anesthesiologist performing the injection. 
Ultimately, Referee Harper found that not one specific doctor’s opinion carried the most 
weight, “rather, when the evidence is pieced together from the various statements and admissions 
of the experts, the totality of the testimony and evidence supports the position of Dr. Thompson 
that ‘something happened’ at” Tenny’s second ESI. Referee Harper noted that it was only after the 
January 2017 MRI that “at least two of the physicians who originally felt that [Tenny’s] complaints 
were consistent with nerve damage” changed their opinions. “No expert gave a persuasive 
explanation for why, if [Tenny] had suffered from iliopsoas bursitis from the date of his second 
injection, it was not discovered for two years thereafter.” Recognizing that the “weight of the 
decision rest[ed] primarily on a temporal relationship” between Tenny’s onset of pain and the 
second ESI, Referee Harper noted that “any persuasive medical evidence in addition to a temporal 
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relationship may tip the scale in favor of causation, even when such opinion does not provide for 
the exact nature of the injury.” 
Referee Harper’s recommended conclusion was that Tenny had proven “by a 
preponderance of the evidence that his left-sided groin condition is a causally related compensable 
consequence of treatment he received for injuries sustained as a result of his accepted industrial 
accident of December 2, 2014.” The Industrial Commission subsequently adopted and confirmed 
Referee Harper’s recommendation as its own. 
The Defendants moved for reconsideration, arguing that the physicians opining in Tenny’s 
favor based their opinions solely on Tenny’s statements that the second injection precipitated the 
onset of pain, e.g., a temporal relationship and therefore an improper basis for their medical 
opinions. The Defendants argued that the referenced medical journal article “does not support a 
finding that it is possible to innervate a nerve in the left groin from a right-side injection.” 
The Industrial Commission denied the motion for reconsideration. The Commission stated 
that Tenny’s testimony as to the onset of his pain was credible but conceded that the exact 
mechanical reasons for Tenny’s pain—beginning after the second ESI—remained unclear. The 
Commission concluded that while the Referee could not ignore the compelling temporal 
relationship, this was not the only basis for his conclusion that something had occurred at the 
second ESI to cause Tenny’s pain. 
The Defendants timely appealed. 
II. 
STANDARD OF REVIEW 
When reviewing a decision of the Industrial Commission, this Court 
exercises free review over questions of law, but reviews questions of fact only to 
determine whether substantial and competent evidence supports the Commission’s 
findings. Substantial and competent evidence is relevant evidence which a 
reasonable mind might accept to support a conclusion. It is more than a scintilla of 
proof, but less than a preponderance. All facts and inferences will be viewed in the 
light most favorable to the party who prevailed before the Industrial Commission. 
Morris v. Hap Taylor & Sons, Inc., 154 Idaho 633, 636, 301 P.3d 639, 642 (2013) (citation 
omitted). 
“[T]his Court ‘must liberally construe the provisions of the worker’s compensation law in 
favor of the employee, in order to serve the humane purposes for which the law was 
promulgated.’ ” Clark v. Shari’s Mgmt. Corp., 155 Idaho 576, 579, 314 P.3d 631, 634 (2013) 
(quoting Jensen v. City of Pocatello, 135 Idaho 406, 413, 18 P.3d 211, 218 (2000)). 
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III. 
ANALYSIS 
A. The Industrial Commission applied the proper legal standards regarding 
causation. 
In his recommendations to the Industrial Commission, Referee Harper observed that a 
temporal relationship alone would not establish causation. (Citing Seamans v. Maaco Auto 
Painting, 128 Idaho 747, 751, 918 P.2d 1192, 1196 (1996)). Referee Harper nonetheless noted that 
“any persuasive medical evidence in addition to a temporal relationship may tip the scale in favor 
of causation, even when such opinion does not provide for the exact nature of the injury.” Referee 
Harper concluded: 
In the present case, Dr. Hajjar’s acknowledgment that significant pain directly at 
the time of the injection could support a causal connection, coupled with Dr. 
Gussner’s opinion that some level of nerve damage might not be picked up on nerve 
studies, in addition to the opinions of Drs. Frizzell and Thompson, and more 
importantly [Tenny’s] course of treatment over the intervening years provides the 
slight weight needed to tip the scale ever so minutely in [Tenny’s] favor. 
The Industrial Commission adopted these findings, and on the Defendants’ motion for 
reconsideration the Commission reiterated the standard regarding causation and concluded that 
Tenny had met his burden. 
 
On appeal, the Defendants argue that the Industrial Commission “recited the correct legal 
standards but then failed to follow them.” The Defendants make three primary arguments: first, 
that the Commission failed to determine whether Tenny met his burden to prove causation “with 
a reasonable degree of medical probability” because the Commission erroneously applied the 
“preponderance of the evidence” standard; second, that the Commission failed to determine the 
weight to be given the medical expert opinions, instead forming its own medical opinion; and 
finally, that the Commission relied solely on the temporal onset of pain to find causation. 
 
In response, Tenny argues that the Commission was free to look at the totality of the 
evidence when making its determination on causation, so long as this determination was supported 
by medical testimony. Tenny points out that physicians’ opinions are only advisory. (Citing Clark 
v. Truss, 142 Idaho 404, 408, 128 P.3d 941, 945 (2006)). Tenny contends that the Defendants’ 
position would raise the standard of proof from a reasonable degree of medical probability to that 
of “medical certainty,” a standard rejected by this Court in Bowman v. Twin Falls Construction 
Company, 99 Idaho 312, 317, 581 P.2d 770, 775 (1978). 
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The Defendants counter, arguing first that the Industrial Commission erred by looking at 
the evidence as a whole to find causation based on a preponderance of the evidence, rather than a 
“reasonable degree of medical probability.” Second, the Defendants argue that the Commission 
“cherry pick[ed] statements from various doctors to support its opinion” rather than relying on 
medical opinion. The Defendants contend that requiring the Commission to ground its analysis in 
medical opinion expressing a reasonable degree of medical probability does not change the 
standard of proof. 
“The claimant carries the burden of proof that to a reasonable degree of 
medical probability the injury for which benefits are claimed is causally related to 
an accident occurring in the course of employment.” [Hart v. Kaman Bearing & 
Supply, 130 Idaho 296, 299, 939 P.2d 1375, 1378 (1997).] The issue of causation 
must be proved by expert medical testimony, id., although the Industrial 
Commission as the finder of fact may consider other evidence as well, including 
evidence regarding credibility. Soto v. Simplot, 126 Idaho 536, 539–40, 887 P.2d 
1043, 1046–47 (1994). 
Wichterman v. J.H. Kelly, Inc., 144 Idaho 138, 141, 158 P.3d 301, 304 (2007). “Medical 
testimony” includes both oral testimony from physicians and evidence from medical records or 
reports. See Jones v. Emmett Manor, 134 Idaho 160, 164, 997 P.2d 621, 625 (2000). 
“Medical proof must establish such causal connection by a reasonable medical probability. 
The medical proof must establish a probable, not merely a possible, causal connection between the 
accident and the disability.” Green v. Columbia Foods, Inc., 104 Idaho 204, 205, 657 P.2d 1072, 
1073 (1983) (citing Bills v. Rich Motor Co., Inc., 96 Idaho 259, 526 P.2d 1095 (1974)). “No special 
verbal formula is necessary when . . . a doctor’s testimony plainly and unequivocally conveys his 
conviction that events are causally related.” Jensen, 135 Idaho at 412–13, 18 P.3d at 217–18 
(citation omitted). Further, “[p]hysician opinions are not binding on the Commission but are 
advisory.” Dilulo v. Anderson & Wood Co., 143 Idaho 829, 831, 153 P.3d 1175, 1177 (2007) 
(citing Jensen, 135 Idaho at 412, 18 P.3d 217). 
The Referee and the Commission applied the proper legal standard regarding causation. 
The Defendants have made much of the Commission’s recitation of the “preponderance of the 
evidence” standard, and argue that the “preponderance” standard applies to a claimant’s burden to 
show that an accident occurred during the course and scope of employment, while the “medical 
probability” standard governs the medical expert testimony. However, this Court has used the 
“preponderance of the evidence” standard interchangeably with the “reasonable degree of medical 
probability” standard due to the definition of “probable” in the context of medical expert testimony 
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in worker’s compensation cases. For example, in Stevens-McAtee v. Potlatch Corporation, 145 
Idaho 325, 332, 179 P.3d 288, 295 (2008), this Court reversed the Commission’s determination 
that a claimant had not shown injury as a result of a compensable accident. This Court noted that, 
while a medical expert may be reluctant to couch an opinion in terms of a “reasonable degree of 
medical probability,” it could “still be clear from his or her testimony that he or she considers that 
a claimant’s injury more likely than not was caused by a work related accident.” Id. at 334, 179 
P.3d at 297 (italics added) (citing Jensen, 135 Idaho at 412, 18 P.3d at 217). Despite the 
Defendants’ argument that the Commission conflated the two standards in evaluating the medical 
opinions, this Court has used the standards interchangeably when referring to medical expert 
testimony. See id.  
To be sure, testimony proffered to a “reasonable degree of medical probability” must 
necessarily be rendered by someone within the medical profession, but it is still based on a more 
probable than not, or a preponderance of the evidence, basis. One standard describes the level of 
education and training undertaken by the medical professional, and the other describes the standard 
of proof for the fact-finder, but they are quantifiably the same (more likely than not). The 
Defendants’ argument appears to be an attack on the weight and competency of the evidence, 
rather than the legal standards by which the evidence is measured. 
 
The Defendants argue that the Commission “pieced” together its own medical opinion in 
violation of the requirement of medical proof as to causation. We recognize, as did the Referee 
and the Commission, that this was a close and difficult case. However, two physicians opined that 
Tenny’s pain was causally related to the second ESI. The decisions below reflect significant 
analysis of the medical records and reports generated by physicians, and the Commission’s 
approach to the many opinions may also be read as an attempt to analyze and reconcile the relative 
credibility of the opinions. See Dilulo, 143 Idaho at 831, 153 P.3d at 1177; see also Lorca-Merono 
v. Yokes Washington Foods, Inc., 137 Idaho 446, 451, 50 P.3d 461, 466 (2002) (concluding that 
the Commission has authority to make its own determination as to the relative weight of expert 
opinions). 
 
The Defendants also argue that the Commission primarily relied on Tenny’s testimony, 
contending this was legal error because temporal relation alone cannot establish causation. The 
Defendants cite several Industrial Commission decisions to highlight this argument, and add that 
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this principle has also been utilized by this Court in civil cases.3 (Citing Coombs v. Curnow, 148 
Idaho 129, 141, 219 P.3d 453, 465 (2009) (“An expert’s opinion does not meet the requisite 
standard of reliability when it is based on the mere temporal connection between the administration 
of a drug and a particular consequence.”).) However, the Defendants’ argument again focuses on 
the weight of the evidence to support the Commission’s conclusion, rather than the standards used 
by the Commission. Referee Harper and the Commission were persuaded by the medical opinions 
that Tenny had established causation, and these medical opinions relied in part on Tenny’s report 
of the onset of pain. Accordingly, a key factual question in this case was when Tenny’s pain began. 
That the Commission made a finding as to this question and used it to support its ultimate 
conclusion does not change the fact that it recited and applied the rule that temporal relation alone 
would not establish causation. Accordingly, we are not persuaded that the Commission applied the 
wrong legal standards in its decision. 
B. Substantial and competent evidence supports the Commission’s determination that 
Tenny established causation by a preponderance of the evidence through medical 
expert opinion to a reasonable degree of medical probability. 
The referee concluded that Tenny had “proven by a preponderance of the evidence that his 
left-sided groin condition is a causally related compensable consequence of treatment he received 
for injuries sustained as a result of his accepted industrial accident of December 2, 2014.” Although 
the referee exhaustively analyzed the evidence available to him, his ultimate conclusion was 
reached through several key findings: (1) that it was possible for the L3 nerve root to innervate the 
area of Tenny’s left-sided groin complaints; (2) that several physicians thought Tenny’s 
complaints were consistent with nerve damage despite the lack of demonstrable evidence; (3) that 
confusion about when the pain initially set in could be explained by the role of the local anesthetic 
during Tenny’s second ESI; and (4) that an injury during the ESI to the nerves innervating Tenny’s 
left-sided groin could not be ruled out by the imaging that accompanied the ESI because they were 
only “point in time” images rather than video. The referee noted that the diagnostic testing that 
                                                 
3 While the Industrial Commission decisions cited by the parties and by the referee and Commission below are not 
binding upon this Court, this rule is similar to this Court’s rule as to medical experts. Compare Boswell v. Edgewood 
Vista, IIC 2015-033326 (March 15, 2019), para. 36 (“While a temporal relationship is always required to support a 
finding of causation between an accident and the injury, the existence of a temporal relationship alone, in the absence 
of substantive medical evidence establishing causation, is insufficient to satisfy Claimant’s burden of proof”), with 
Coombs v. Curnow, 148 Idaho 129, 141, 219 P.3d 453, 465 (2009) (concluding that temporal causation was not basis 
of expert opinion when qualified expert was able to provide a scientific explanation of effect of administration of drug 
on decedent). 
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was performed did not reveal iliopsoas bursitis until January 2017, roughly two years after the ESI, 
and that the treatment Tenny underwent would be “overkill” for treatment of bursitis. In addition, 
the referee noted that the pain pump did not relieve Tenny’s pain.  
The referee’s ultimate interpretation of the medical opinions was that if Tenny experienced 
immediate pain at the time of the second ESI, this would support a finding of a nerve injury. The 
referee found Tenny’s testimony credible, calling Tenny’s testimony “[b]y far the most compelling 
evidence in favor of causation.” The referee concluded: 
In the present case, Dr. Hajjar’s acknowledgment that significant pain directly at 
the time of the injection could support a causal connection, coupled with Dr. 
Gussner’s opinion that some level of nerve damage might not be picked up on nerve 
studies, in addition to the opinions of Drs. Frizzell and Thompson, and more 
importantly [Tenny’s] course of treatment over the intervening years provides the 
slight weight needed to tip the scale ever so minutely in [Tenny’s] favor. 
The referee’s findings were adopted and again confirmed by the Commission in its order denying 
reconsideration: “At the end of the day we are left with the fact that the onset of [Tenny’s] left 
groin discomfort coincides with the administration of the injection.” 
On appeal, the Defendants argue that the Commission’s finding of causation is unsupported 
by substantial and competent evidence. In particular, the Defendants contend that “the evidence 
lacks any objective foundation upon which a finding of causation can reasonably be based.” The 
Defendants assert that Dr. Frizzell and Dr. Thompson did not point to any objective evidence to 
support their conclusion that Tenny’s groin pain was from nerve damage. The Defendants maintain 
the objective evidence shows that the groin pain was not caused by nerve damage: (1) imaging of 
the injection, (2) the outcome of Tenny’s decompression surgery, (3) physical findings from 
treating doctors and during the IME, and (4) the nerve conduction studies. Instead, the Defendants 
contend, the only objective evidence of the cause of Tenny’s condition is the MRI of the pelvis 
performed January 2017, showing iliopsoas bursitis. 
In response, Tenny argues that the Commission did not rely on temporal relation alone and 
sets out at length the opinions expressed by his several doctors (including Dr. Hajjar and Dr. 
Gussner) as treatment unfolded. Tenny reasons that this medical testimony made it important for 
the Commission to determine when exactly his left-sided groin pain began. Tenny urges this Court 
to “reject the notion that there has to be objective evidence to support causation[,]” arguing that 
“there are some injuries that medical objective testing is not adequate enough to detect.” 
13 
The Defendants respond by arguing that Tenny misconstrues the medical records because 
the medical records actually show “a lack of objective evidence of nerve damage[.]” The 
Defendants reason that “requiring medical opinions to be supported by objective evidence is 
consistent with requiring something more than a possibility.” The Defendants reiterate that the 
medical experts supporting Tenny’s claim did not render opinions based on objective evidence and 
characterize the opinions of Dr. Frizzell and Dr. Thompson as “unsubstantiated conjecture.” The 
Defendants assert that the Commission “took great liberty in utilizing isolated statements by Dr. 
Hajjar and Dr. Gussner even though the actual opinions by those providers is that the right-sided 
injection did not cause the left-sided groin pain.” 
The Commission is free to determine the weight to be given to the testimony 
of a medical expert. Lorca–Merono[, 137 Idaho at 452, 50 P.3d at 466]. We will 
not disturb the Commission’s conclusions as to the weight and credibility of expert 
testimony unless such conclusions are clearly erroneous. Id. 
Anderson v. Harper’s Inc., 143 Idaho 193, 197, 141 P.3d 1062, 1066 (2006). “On appeal, this 
Court is not to re-weigh the evidence or consider whether it would have reached a different 
conclusion from the evidence presented.” Id. (citing Warden v. Idaho Timber Corp., 132 Idaho 
454, 457, 974 P.2d 506, 509 (1999)). 
 
We conclude that the Commission’s determination is supported by substantial and 
competent evidence. First, while the Defendants argue that the Commission depended on several 
non-expert findings to support its conclusion, it is clear that Tenny had two medical expert opinions 
stating that Tenny’s groin condition arose from whatever occurred during the second ESI. We are 
not persuaded, as argued by the Defendants, that Dr. Frizzell somehow withdrew his opinion by 
acknowledging that the studies he cited were not entirely on point. The referee acknowledged the 
point for which Dr. Frizzell cited those studies, i.e., that L3-4 radiculopathy could account for 
groin pain, and that the nerve conduction studies would not assess nerve pain, only 
dysfunction/damage. Dr. Frizzell’s medical opinion by itself constitutes far more than a scintilla 
of evidence to support the Commission’s decision. 
Second, the Commission’s decision is not rendered clearly erroneous by the lack of 
objective evidence to establish the exact mechanism of Tenny’s symptomology. See Anderson, 
143 Idaho at 197, 141 P.3d at 1066. In Anderson, the claimant underwent cervical fusion surgery 
related to an industrial accident. Id. at 195, 141 P.3d at 1064. Almost immediately after the surgery, 
the claimant developed tremors in his hands and arms, making it difficult for him to grasp and hold 
14 
objects. Id. The claimant then underwent a battery of treatment and testing as doctors strained to 
determine the cause of his tremors. Id. at 196, 141 P.3d at 1065. One of the claimant’s treating 
doctors sent the claimant for other testing, prescribed medication that did not control the tremors, 
ruled out several explanations, and stated, “[t]he mechanism of the upper arm symptoms is still 
not clear but does appear to relate to problems in the back.” Id. The Commission ultimately relied 
on this doctor’s reports to conclude that the tremors were causally related as a compensable 
consequence of the claimant’s treatment. Id.  
On appeal, this Court affirmed, commenting, “[t]aken in context, the Commission did not 
err in interpreting this statement as an expression of a medical probability rather than merely a 
medical possibility. The words ‘not clear’ related to the exact mechanism of causation, not to the 
fact of causation.” Id. at 197, 141 P.3d at 1066. In Anderson, despite a lack of objective evidence 
as to what occurred at the cervical fusion surgery and what mechanism caused the tremors, this 
Court affirmed the Commission’s determination that the treating doctor’s opinion established 
causation. Here, while there is objective evidence in the form of the January 2017 MRI showing 
iliopsoas bursitis, Dr. Frizzell was unconvinced that this imaging—two years after the fact—
explained the pain that occurred immediately after the second ESI.  
Third, this Court has found that causation was established even where expert physicians 
expressed uncertainty about the ultimate cause of the injury, but where alternative causes were 
ruled out and where great weight was placed on the claimant’s testimony of temporal relation. See, 
e.g., Anderson, 143 Idaho at 197, 141 P.3d at 1066; and Jensen, 135 Idaho at 413, 18 P.3d at 218. 
In Jensen, the claimant suffered a medical reaction after ingesting pain medication provided by his 
supervisor (which was subsequently discarded before it could be tested), and then experienced 
total renal failure two days after this reaction. 135 Idaho at 407, 18 P.3d at 212. The Industrial 
Commission concluded that while the medical reaction was causally related to the claimant’s work, 
his subsequent renal failure was not. Id. at 408–09, 18 P.3d at 213–14. The parties cross-appealed. 
This Court noted that a physician had provided deposition testimony that alternative explanations 
had been ruled out: 
Q. In the inquiry, the index of suspicion requires that we say whatever was in there 
has got to be right on the top of our list because of the sequence of events; right? 
A. I’m trying to be exactly correct in how I answer that. In the list of my speculation 
of what might have caused the renal failure, then it would be at the top of that list 
of my speculation. I don’t know of anything that would be higher, but I have no 
evidence to support that it was the cause. 
15 
Q. That’s right. That’s right. Nobody does, and nobody will if the medication was 
all destroyed? 
A. I think that’s probably fair. That’s correct. 
Jensen, 135 Idaho at 410, 18 P.3d at 215 (italics in original). 
This Court ultimately affirmed the Commission’s conclusion that the medical reaction was 
causally related to the claimant’s work, pointing to non-expert testimony of the claimant’s 
supervisor, the closeness in time between ingesting the pain medication, and the physician’s 
testimony that he knew of nothing that would be higher on his list of speculation. See id. at 411, 
18 P.3d at 216 (“Therefore, while perhaps the evidence does not overwhelmingly establish a 
definite causal link between the Pain-Off ingestion and Jensen’s renal failure, it does provide 
substantial and competent evidence to support the referee’s finding of fact number 37.”). Notably, 
this Court reversed the Commission’s conclusion that the subsequent renal failure was not related: 
[W]hile Dr. Hearn expressly refused to say the words “reasonable degree of medical 
probability,” it is clear from his testimony that he considered that Jensen’s renal 
failure to be more likely than not caused by his ingestion of Pain-Off . . . . Therefore, 
we hold that Dr. Hearn’s testimony, coupled with the facts, adequately established 
a causal connection between Jensen’s Pain-Off ingestion and his renal failure, when 
Dr. Hearn indicated that he did “not know of anything that would be higher” on his 
list of speculation. 
Id. at 412–13, 18 P.3d at 217–18. 
 
Similarly, as discussed above, this Court in Anderson affirmed the Commission’s finding 
of causation, noting that 
[t]here were other facts supporting the Commission’s finding of causation. 
Claimant testified that the tremors began “almost immediately right after surgery,” 
while he was still in the hospital; that he experiences a burning sensation in his neck 
signaling the onset of the tremors; and that there was no evidence of any other cause 
of the tremors. 
Anderson, 143 Idaho at 197, 141 P.3d at 1066. 
 
Here, the Commission’s conclusion that there was a causal link between Tenny’s second 
ESI and his intractable groin pain is supported by substantial and competent evidence. First, the 
Commission’s conclusion is supported by medical testimony to a reasonable degree of medical 
probability. Second, the non-opinion evidence also supports this conclusion. Objective evidence 
of what could cause similar pain—e.g., iliopsoas bursitis—did not emerge until two years after the 
onset of pain. Dr. Thompson and Dr. Frizzell noted that pain associated with iliopsoas bursitis 
should have responded to Tenny’s course of treatment, whereas his pain was abated only by the 
16 
pain pump, which to both doctors suggested neuropathic issues. The Referee and Commission 
clearly rejected the Defendants’ position that iliopsoas bursitis began immediately after the second 
ESI but was not detected by a CT scan, or treated by a treatment plan which should have alleviated 
his pain, and that two injections performed by Dr. Gussner missed the bursae entirely or provided 
no relief for the purported bursitis. 
We recognize that the Commission uses several qualifiers in describing the weight of the 
evidence. The Commission also pointed to several other facts not relied upon by any of the 
physicians in establishing their medical opinions, e.g., that Tenny’s pain levels immediately after 
the second ESI could have been affected by the local anesthesia, or that the fluoroscopic imaging 
was point-in-time. We note that such reliance invited appeal. However, the Commission’s 
conclusion ultimately rested on Dr. Thompson’s and Dr. Frizzell’s opinions, as corroborated and 
substantiated by Tenny’s testimony about the timing of the onset of his groin pain. In light of the 
deference owed to the Commission’s findings of fact, and because the Commission was persuaded 
by medical opinions rendered to a reasonable degree of medical probability, we affirm. See 
Anderson, 143 Idaho at 197, 141 P.3d at 1066; Jensen, 135 Idaho at 413, 18 P.3d at 218. 
C. Tenny’s additional issue is rendered moot because this Court is affirming the 
Commission’s decision. 
The referee found that Dr. Thompson had not reviewed any documentation from other 
physicians before reaching her conclusion that Tenny’s pain was a result of something occurring 
at the second ESI. Tenny has raised an additional issue on appeal, arguing that this finding is 
clearly erroneous. In response, the Defendants argue that if Tenny seeks any affirmative relief 
through this additional issue, Tenny should have filed a cross-appeal. 
Idaho Rule of Appellate Procedure 15(a) states: 
Right to Cross-Appeal. After an appeal has been filed, a timely cross-
appeal may be filed from any interlocutory or final judgment or order. If no 
affirmative relief is sought by way of reversal, vacation or modification of the 
judgment or order, an issue may be presented by the respondent as an additional 
issue on appeal under Rule 35(b)(4) without filing a cross-appeal. 
I.A.R. 15(a). “In Idaho, a timely notice of appeal or cross-appeal is a jurisdictional prerequisite to 
challenge a determination made by a lower court. Failure to timely file such a notice shall cause 
automatic dismissal of the issue on appeal.” Hamilton v. Alpha Servs., LLC, 158 Idaho 683, 693, 
351 P.3d 611, 621 (2015) (quoting Miller v. Bd. of Trustees, 132 Idaho 244, 248, 970 P.2d 512, 
516 (1998) (internal quotation marks omitted)). 
17 
 
Although the Commission’s conclusion that Dr. Thompson reviewed no documentation 
from other physicians before reaching her opinion is contradicted by Dr. Thompson’s own 
deposition, it is unnecessary for this Court to rule on the question Tenny has raised because we are 
affirming the Commission’s decision. We are not modifying the Commission’s decision, and 
Tenny has ultimately prevailed. 
D. No attorney fees will be awarded. 
On appeal, Tenny seeks an award of attorney fees under Idaho Code section 72-804, 
arguing that his employer appealed to this Court “without any reasonable basis.” Tenny asserts 
that this Court is being asked to reweigh the evidence “under the guise of a misapplied standard of 
law.” In response, the Defendants contend that it has a reasonable ground for an appeal, because 
the Industrial Commission failed to follow the proper legal standards for reaching a decision. 
(Citing Aguilar v. Indus. Special Indem. Fund, 164 Idaho 893, 899, 436 P.3d 1242, 1248 (2019)).  
 
Idaho Code section 72-804 allows for an award of attorney fees where a court “determines 
that the employer or his surety contested a claim for compensation made by an injured employee 
. . . without reasonable ground[.]” I.C. § 72-804. This Court has declined to award attorney fees to 
a claimant-respondent under section 72-804 even where the proper legal standards were followed 
by the Commission and where substantial and competent evidence supported the Commission’s 
decision, in light of a close evidentiary call made by the Commission. See Seamans, 128 Idaho at 
754, 918 P.2d at 1199. 
Here, the Commission observed this case presented a close evidentiary call. The decisions 
of the referee and the Commission reflect a significant amount of qualifying language in their 
interpretation of the evidence. Although the Commission followed the appropriate legal standards, 
it used equivocal language which invited appeal. The Defendants have not pursued their appeal 
frivolously, so attorney fees will not be awarded to Tenny. 
IV. 
CONCLUSION 
For the foregoing reasons, this Court affirms the decision of the Industrial Commission. 
No attorney fees are awarded on appeal. Costs, as a matter of right, are awarded to Tenny. 
Chief Justice BEVAN, Justices BURDICK, BRODY, and MOELLER CONCUR.