Case Title: Blackburn v. WCD and Marrowbone

Citation: 

Docket Number: 

State: west-virginia

Court: West Virginia Supreme Court

Date: 2002-11-27T00:00:00Z

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IN THE SUPREME COURT OF APPEALS OF WEST VIRGINIA September 2002 Term FILED November 27, 2002 RORY L. PERRY II, CLERK SUPREME COURT OF APPEALS OF WEST VIRGINIA RELEASED November 27, 2002 RORY L. PERRY II, CLERK SUPREME COURT OF APPEALS OF WEST VIRGINIA No. 29543 JASPER A. BLACKBURN, Claimant Below, Appellant, V. WORKERS’ COMPENSATION DIVISION AND MARROWBONE DEVELOPMENT COMPANY, Respondent Below, Appellees. Appeal from the Workers’ Compensation Appeal Board Appeal No. 50695 Claim No. 96-26746 REVERSED AND REMANDED Submitted: October 8, 2002 Filed: November 27, 2002 Linda S. Rice James M. Robinson Robinson and Rice, L.C. Huntington, West Virginia Attorneys for the Appellant Darrell V. McGraw, Jr. Attorney General Robert M. Nunley Senior Assistant Attorney General Charleston, West Virginia Attorneys for Appellee, Workers’ Compensation Division Robert J. Busse Jackson & Kelly PLLC Charleston, West Virginia Attorney for Appellee, Marrowbone Development Company CHIEF JUSTICE DAVIS delivered the Opinion of the Court. JUSTICE ALBRIGHT concurs, in part, and dissents, in part, and reserves the right to file a separate opinion. JUSTICE STARCHER concurs and reserves the right to file a concurring opinion. JUSTICE MAYNARD dissents and reserves the right to file a dissenting opinion. SYLLABUS BY THE COURT 1. The Workers’ Compensation Division is directed to establish appropriateguidelinesforthespecificmannerinwhichaudiograms should be administered. In developing these guidelines, the Division should consider, inter alia: (1) whether all audiograms should be administered using a uniform brand and model of audiometer; (2) whether guidelines should be adopted for when and how audiometers should be uniformly calibrated; (3) establishing a definitive margin of error; (4) requiring audiologists to perform specificreliabilityandvaliditychecksduringthecourseofan audiogram; (5) modifying the existing WC-123HL form to allow for the reporting of any required reliability and validity checks;(6)whetherthespeechdiscriminationportionofallaudiograms should be conducted using only a recorded voice; and (7) what method should be used to select an appropriate audiogramwhentwoaudiogramsthatareboth rated “good” differ by more than the established margin of error. 2. Until such time as the Workers’ Compensation Division has promulgated additionalrulesforadministeringaudiograms in workers’ compensation hearing loss cases, when two valid audiograms that have both been performed after the claimant’s date of last exposuretooccupationalnoisearewithinamarginoferrorofplusorminustendecibels, and do not differ by the same amount or in the same direction at all frequencies, the rule of liberalityshouldbeapplied,andtheclaimantshouldbegranted a permanent partial disability i award based upon the audiogram demonstrating a higher level of hearing loss. 3. Untilsuchtime as the Workers’ Compensation Division has promulgated additionalrulesforadministeringaudiogramsinworkers’ compensation hearing loss cases, when two valid audiograms that have both been performed after the claimant’s date of last exposuretooccupationalnoise fall outside a margin of error of plus or minus ten decibels, or arewithinamarginoferrorof plus or minus ten decibelsbutdifferinthesameamountorin thesamedirection at all frequencies, then the claimant should undergo additional audiometric testing. Presumably the third audiogram will be within a margin of error of ten decibels of one of the existing two audiograms, and will not differ by the same amount or in the same direction atallfrequencies,sothattheruleofliberalitymaybe applied to the two audiograms falling within this criteria, and the claimant may be granted a permanent partial disability award based upontheaudiogramdemonstrating a higher level of hearing loss. If a claimant chooses to have theadditionaltestingperformedbyaphysicianofhisorherchoosing, then the claimant shall pay the expense of the testing. If, however, the claimant chooses to have the Division select the examining physician, then the Division shall be responsible for such cost. Davis, Chief Justice: Thisappealpresents a challenge to the way permanent partial disability awards havebeendeterminedinWorkers’Compensation hearing loss cases since this Court handed 1 down its decision in Bilbrey v. Workers’ Compensation Commissioner, 186 W. Va. 319, 412 S.E.2d 513 (1991). Particularly, Mr. Jasper Blackburn challenges the practice of automaticallybasing a disability award on the audiogram demonstrating the lowest level of hearinglosswhenthereisadiscrepancybetween audiograms that exceeds the margin of error. We find that additional rules should be promulgated to create uniformity in the way audiograms areconductedandtoestablisha method for selecting the best valid audiogram. Consequently, we direct the Division to promulgate such rules. Until such time as these rules are in place, we find that where two valid audiograms are within a margin of error of plus or minus ten decibels,theliberalityruleshouldbeapplied, and the claimant should be given the benefit of the audiogram demonstrating a higher level of hearing loss. Where two valid audiograms differ byamargingreaterthanplusorminustendecibels,thenanadditionalaudiogramshouldbe performed. I. FACTUAL AND PROCEDURAL HISTORY Mr.JasperBlackburn(hereinafter“Mr.Blackburn”),theclaimantbelowand appellantherein,workedformorethantenyears as a mechanic for Marrowbone Development Company (hereinafter “Marrowbone”), respondent below, appellee herein. He was also employedbyMarrowbone as a heavy equipment operator for just over one-and-one-half years. 1 1According to his WC-123HL form, Mr. Blackburn was a mechanic for (continued...) 2 TherecordindicatesthatMr.Blackburn last worked for Marrowbone on September 4, 1995, when he was laid off. On October 30, 1995, Mr. Blackburn was examined by Dr. Joseph Touma andunderwentaudiometric testing administered by Laura Bedell Garish, a certified Clinical Audiologist, to ascertain his level of occupational noise induced hearing loss. 2 The reliability of the audiogram was ranked at fair to good. Based upon the examination and the results of the audiogram,Dr.ToumaconcludedthatMr.Blackburn had suffered a work-related noise-induced hearing loss and determined that he had sustained a 10.65% impairment as a result of this hearingloss. Mr. Blackburn then initiated a claim with the Workers’ Compensation Division (hereinafter “the Division”) by filing a “Report of Occupational Hearing Loss” 3 on November 27, 1995. His claim was held compensable on February 21, 1996, and Mr. Blackburn was referred by the Division to Dr. Sherman Hatfield. Dr. Hatfield and his staff evaluated Mr. Blackburn on March 25, 1996. As part of the evaluation, Mr. Blackburn was given an audiogrambyBrendaD.George, a certified audiologist. 4 The reliability of the audiogram was 1(...continued) Marrowbone from February 24, 1982, until January 31, 1993. During most of the period between January 1993andFebruary1994,Mr.Blackburnwasemployedasamechanicfor another company in Kentucky. He then returned to Marrowbone and worked as a heavy equipmentoperatorfromFebruary21,1994,until September 4, 1995, when he was laid off. 2The speech discrimination portion of the audiogram was administered using a monitored live voice as opposed to a recorded voice. 3This report is also commonly identified as a “WC-123HL” form. 4Aswiththeaudiogram performed for Dr.Touma,thespeechdiscrimination portion of this audiogram was administered using a monitored live voice. 3 rated good. Based upon the evaluation, Dr. Hatfield recommended a .73% whole person impairment. Nearlytwo years later, by order entered March 4, 1998, the Division granted Mr. Blackburna10.65% permanent partial disability (hereinafter “PPD”) award based upon Dr. Touma’s recommendations. Both parties protested the order and it was referred to the Workers’ Compensation Office of Judges (hereinafter “the OOJ”). In connection with the protest, Dr. Touma was deposed on November 3, 1998. He testified that Dr. Hatfield’s audiogramrevealedbetterthresholdsthanhisown,andthatDr. Hatfield’s audiogram had also producedamoreaccuraterepresentationof Mr.Blackburn’struehearinglossimpairment. Thereafter,byorderenteredJune8,1999,theOOJ affirmed the Division’s award of 10.65% PPD. However, the order stated that because Dr. Hatfield’s report had not been included in the record, it had not been considered by the OOJ in reaching its decision in this case. Marrowbone subsequently filed a motion for reconsideration based upon the Division’s failure toincludeDr.Hatfield’s report in the record submitted to the OOJ. Marrowbone’s motion was granted, and the OOJ subsequently issued an order finding that the audiogram obtained by Dr. Hatfield was the most reliable. Based upon Dr. Hatfield’s audiogram, the OOJ reduced Mr. Blackburn’s PPD award to .73%. On appeal, the Workers’ Compensation Appeal Board (hereinafter“theWCAB”)affirmedthe .73%PPDawardbyorderenteredMarch31,2000. Mr. Blackburn then appealed the WCAB order to this Court, and oral argument was had on June 4,2002. Thereafter, on June 13, 2002, this Court, on its own motion, scheduled this case for 4 re-argumentanddirected the parties to file briefs addressing specific questions posed by the Court. Specifically, the Court asked the parties to address the following issues: (1) are all tests being done at the level as specified in West Virginialaw;(2)istherea standardized system ofdetermining reliability of the tests; (3) set forth reasons why this Court should retain its holding in James Bilbrey vs. WCC and Ranger Fuel Corporation, 412 S.E.2d 513 (W. Va. 1991), adopt the rule of liberality, or adopt an alternative, and if so, what alternative; (4) explain the methods used to ascertain whether tests are being administeredinaccordance with West Virginia law and rules and regulations; and discuss the impact of a margin of error. Thepartiesareherebydirected to inform the Court of any differing expert opinions which have come about since 1991 when the Court decided Bilbrey[ v. Workers’ Comp. Comm’r, 186W.Va.319, 412 S.E.2d 513 (1991)], regarding how the “best valid audiogram” is to be determined when all audiograms are reliable and within the margin of error. Further,thepartiesareherebydirectedto advancetothe Court their own recommendations for resolving conflicts in the evidence in work-related hearing loss claims. Finally, the parties are hereby directed to relay to the Courtthediffering schools of thought, if any, as to whether work- related hearing loss is progressive or static. The case was re-argued and submitted for decision on October 8, 2002. II. STANDARD OF REVIEW In this case we are asked to reconsider our prior holding in Bilbreyv. Workers’ Comp. Comm’r, 186 W. Va. 319, 412 S.E.2d 513 (1991), and to revise the standards for 5 evaluatingWorkers’Compensation hearing loss claims. These present legal questions which we review de novo. “As we said in Barnett v. State Workmen’s Compensation Com[m]’r., 153 W. Va. 796,812,172 S.E.2d 698, 707 (1970), ‘[w]hilethefindingsoffactofthe [WCAB] are conclusive unless theyaremanifestlyagainsttheweightoftheevidence, the legal conclusions of the appeal board,baseduponsuchfindings,are subjecttoreviewbythecourts.’ Conclusions of law are subject to de novo scrutiny. Syl. pt. 3, Adkins v. Gatson, 192 W. Va. 561, 453 S.E.2d 395 (1994); Syl. pt. 1, Randolph County Board of Education v. Scalia, 182 W. Va. 289, 387 S.E.2d 524 (1989). Where the issue on an appeal is clearly a question of law or involving an interpretation of a statute, we apply a de novo standard of review. Syl. pt. 1, Chrystal R.M. v. Charlie A.L., 194 W. Va. 138, 459 S.E.2d 415 (1995); Syl. pt. 1, University of West Virginia Bd. of Trustees on Behalf of West Virginia University v. Fox, 197 W. Va. 91, 475 S.E.2d 91 (1996).” Rhodes v. Workers’ Comp. Div., 209 W. Va. 8, 12, 543 S.E.2d 289, 293 (W. Va. 2000) (quoting Conley v. Workers’ Comp. Div., 199 W. Va. 196, 199, 483 S.E.2d 542, 545 (1997)). III. DISCUSSION In our discussion of this case, we first review the parties’ contentions with respecttotheerrorassigned by Mr. Blackburn. We then summarize their various answers to the particular questions raised by this Court. After providing this information, we then announce our decision of this matter. 6 A. Assignment of Error Mr.Blackburn argues on appeal that this Court’s opinion inBilbreyv.Workers’ Comp. Comm’r, 186 W. Va. 319, 412 S.E.2d 513 (1991), is inconsistent with the liberality rule and should no longer be followed. Mr. Blackburn contends thatBilbrey’s directive,which states that an audiogram showing the least amount of hearing loss should be used to determine theamountofnoise-inducedhearinglosswhen there is a difference between audiograms which isgreaterthanthemarginoferror,failstoacknowledgethat an audiogram is a subjective test. Marrowbone responds that this Court in Bilbrey correctly recognized the universallyacceptedmedical principle that any deterioration in an individual’s hearing after the dateoflast exposure is duetosomefactorotherthantheprioroccupationalnoiseexposure. Followingthisprinciple,Marrowbone notes,Drs.Hatfield and ToumabothagreedthatDr. Hatfield’s audiogram should be used to determine the degree of whole person impairment sufferedbyMr.Blackburn. Marrowbone further submits that the rule of liberality is intended to resolve conflicts in the evidence. Marrowbone points out that there is no conflict in the evidence presented in this case due to the agreement of the examining physicians that Dr. Hatfield’s test represents the most accurate measure of Mr. Blackburn’s impairment. Moreover,Marrowbone argues that hearing loss claims are unique by nature, as recognized by this Court in Bilbrey, and, due to the inherent differences between hearing loss claims and other types of claims (particularly in the fact that noise induced hearing loss is not a 7 progressive condition – as are other types of occupational conditions), the principles this Courtestablishedin Bilbrey were correct and should not be repudiated. Marrowbone finally observes the liberality rule was well established at the time Bilbrey was decided, and thus it is not a valid basis upon which to alter Bilbrey. TheDivision responds that in view of the concurring opinions of Drs. Touma and Hatfield,theonlyevaluatingotolaryngologists ofrecordinthis claim, the reliable, probative andsubstantialevidenceofrecord overwhelmingly supports the decision of the OOJ. Hence, the WCAB order affirming the OOJ was not plainly wrong. Additionally, the Division contends that the treatment of hearing loss claims pursuant toBilbrey isnotinconsistentwith the liberality rule. The Division directs this Court to the well-established principle that the liberalityruledoesnotrelieveclaimantsoftheburdenofsubstantiatingtheirclaims. In this case,theDivisionmaintains,bothevaluating physicians agree that the proper measure of Mr. Blackburn’s impairment is .73%. Thus, there is no proper evidence supporting a higher award. B. Issues Raised by the Court In response to the Court’s questions on re-hearing, the parties to this action agreedamongthemselvestoutilizetheaffidavitsof twodoctors:Dr.GaryD.Harris,Ph.D., acertifiedaudiologist,andDr.WilliamC.Morgan,Jr.,M.D.,anotolaryngologist. Relying on these two experts, the parties’ answers to the Court’s questions are largely in agreement. Following is a brief summary of the answers to each of the Court’s questions. 8 1. Are all tests being done at the level specified in West Virginia law? The partiesagreethatallaudiometrictestscurrentlybeing relied upon to either support a diagnosis of noise-induced hearing loss or to ascertain the appropriate level of disability resulting therefrom are being done at the levels specified in West Virginia law, specifically, W. Va. Code § 23-4-6b (1986) (Repl. Vol. 2002).5 The parties further agree that there are no requirements as to the order in which the tests are performed, and no uniformity as to the mannerinwhichthetestsarebeingconducted. The Division additionally explains that since atleast1958, it has been recognized that certain methods of presenting the pure tones used in an audiogram can affect the patient’s responses. 2. Is there a standardized system of determining reliability of the tests? The parties’ responses to this particular issue differ somewhat. Mr. Blackburn contends that there is no uniform system for determining the reliability of audiometric testing as the outcome of audiometric testing is essentially subjective. Marrowbone, on the other hand, asserts that the audiologist’s rating of a test as “good,” “fair,” or “poor” provides one method ofdeterminingthereliabilityofthetests. However, Marrowbone suggests that any rating other than“good”byanaudiologist should be accompanied by a specific explanation of the reason fortheranking. Marrowbone also states that there are other reliability indicators included on 5W. Va. Code § 23-4-6b(1) sets forth the sound frequencies at which hearing loss is to be measured. The Division notes that these frequencies correspond with the frequencies currently recommended for assessing hearing impairment by the American Academy of Otolaryngology and the American Medical Association. 9 theWC-123HLform,6 but in its experience the Division ignores these factors and relies solely on the audiologist’s ranking. The Division agrees that the audiologist’s rating is a method of determining reliability, and submits that there are a few other standardized methods for assessing the reliability of an audiogram. For instance, audiologists/ontologists typically conduct what is referred to as an SRT/PTA Comparison 7togaugethereliabilityofatest while itisbeingperformed. Comparing two audiograms provides another measure of reliability. A thirdmethodofassessingreliabilityistorepeatthesame pure tones at different points during an evaluation, as it is virtually impossible for an individual to remember whether or not he respondedtoaparticulartoneafterhavingheardothertonesinthemeantime. The Division however, does not, assert that this method is used regularly, and we are aware of no requirementfor its employment. Finally, the Division asserts that an indirect test of reliability arises from the education and training required in order to become an audiologist under W. Va. Code §§ 30-32-1 to -23 (Repl. Vol. 2002). 6Marrowbonerefersspecificallyto:(1)thedatesonwhichtheaudiometer was last calibrated (noting there are three types of calibration, namely “biennial exhaustive electroacousticcalibration,” “semi-annualelectroacoustic calibration,” and “daily biological calibration”); (2) whether the audiologist holds a “Certificate of Clinical Competence in Audiology”; and (3) the speech reception threshold and pure tone average for each ear (for definitionsoftheterms “speech reception threshold” and “pure tone average,” seeinfra note 7). 7The Division explains that SRT refers to “speech reception threshold” and “isdefinedasthelowestlevel,intermsofvolume,atwhichapatient can repeat approximately fifty per cent [sic] of the “spondees” presented to him. A spondee is a two-syllable word with equalemphasisoneachsyllable, such as ‘baseball.’” The Division further explains that, “PTA standsforpuretoneaverageandhistoricallyhasbeentheaverageforthethreethresholdsat five hundred, one thousand, and two thousand hertz.” 10 3. Should the Court to retain its holding in Bilbrey, adopt the rule of liberality in hearing loss cases, or adopt an alternative rule? Mr. Blackburn again argues that Bilbrey should be abandoned because the measurement of noise-induced sensorineural hearing loss is subjective and lacks any standardized method of evaluating reliability. Mr. Blackburn submits that all evidence should be presumed reliable unless it can be proven otherwise and the claimant should be entitled to the benefit of the most favorable results obtained. Both Marrowbone and the Division contend this Court’s holding inBilbrey should be retained as the medical foundation upon which Bilbrey is based has not changed. Occupationalhearinglossisanon-progressive occupational disease. This unique medical fact makes it inappropriate to use the rule of liberality to choose the higher of two widely-varying audiograms when attempting to ascertain the proper amount of impairment sustained by a claimant whose exposure to noise ended prior to the audiograms being administered. The Division additionally asserts that to use the rule of liberality in such cases would allow a judicially-created ruletotaketheplaceofprovenscientificfact and would relieve claimants of their burden of establishing their claims. 4. What are the methods used to ascertain whether tests are being administered in accordance with West Virginia law and rules and regulations? In an answerthatissomewhatunresponsive to the specific question asked, Mr. Blackburn submits thatWestVirginialaws,rules, and regulations pertaining to how tests are being administered are inadequate. For example, he states that there are no statutes or regulations providing 11 standards for the calibration of audiometers, for testing environments, or for any other equipment that may be used. Acknowledging that physicians are permitted to consider only noise-induced hearing loss in determining the degree of a claimant’s impairment, Mr. Blackburncomplainsthatithasbecomeawidespreadpractice among physicians to adjust the thresholdhearingshiftsmeasuredateachfrequencytoreflectotherfactors,particularly the effects of the natural aging process, even in the absence of any evidence that a particular claimant’s hearing has actually been diminished by such factors. Mr. Blackburn contends that this practice is inconsistent with legislative intent asneitherthestatute nor the regulations provide for any “adjustment” of test results based upon statistical probability or mere speculationbyanevaluating physician. Marrowbone contends that the only method utilized bytheDivisiontoensurethattestingisbeing conducted in accordance with West Virginia law andrulesisalettertoitsevaluatingprofessionalstitled “Report Outline For Permanent Partial DisabilityEvaluation(Noise-Induced HearingLossOnly),” whichoutlines the information soughtbytheDivisionandtheproceduretheDivisionrequeststhespecialists to follow. The Division explains that, at this time, the only method in use to ascertain whether tests are being administeredinaccordancewithWestVirginia law, rules, and regulations is a visual inspection by its claims managers of the reports received from physicians and/or audiologists.8 8The Division explains that whenitreceivesanaudiogram,theaudiogram is reviewedbyaClaimsManager who ascertains whether: (a) the audiogram was conducted at the soundfrequencylevelsspecifiedbystatute;(b) the audiogram was performed by a certified audiologist;and(c)allothertestingrequiredbystatuteandregulationshasbeenperformed (i.e.,airandboneconductiontesting,speechreceptionthreshold, and speech discrimination (continued...) 12 5. What is the impact of the margin of error? Before relating the parties’ commentsregardingtheimpactofthemarginoferror,itshould be noted that there presently is no law orregulationinplaceestablishingthe acceptable margin of error for hearing loss cases in this State. Mr. Blackburn and the Division are both supportive of using a margin of errorofplus or minus five decibels when comparing audiograms by the same audiologist on the same machine that were administered on two different occasions. They also agree that a marginoferrorofplusorminustendecibelsisacceptable when comparing audiograms by different audiologists on different machines, due to possible differences in earphone placement and calibration. Marrowbone, however, considers a difference of plus or minus ten decibelstobetoogreat,andurgesthatthemarginoferrorshouldbeset at plus orminusfive decibels even when two audiograms have been administered at different clinics. Marrowbone and the Division effectively agree that the margin of error should not differ by the same amount, or in the same direction, at all frequencies. In other words, there should be interweaving between two valid audiograms. 9 In the absence of interweaving, they argue, then 8(...continued) testing). 9Inhis affidavit, Dr. Harris explains that he uses the term “interweaving,” to refer to the fact that two valid audiograms “will tend to interweave with one audiogram showing some thresholds better and some thresholds worse than the comparison audiogram.” Dr. Harris states that differentaudiogramswith thresholds that vary no more than 10 dB, usually suggest unchanged hearing. However, these different audiograms, in the absence of any real change in hearing, may (continued...) 13 the audiogram results should then be considered suspicious. Using the instant case as an example,MarrowbonenotesthatMr.Blackburn’stwoaudiogramsshowedworseresults at every one of the eight relevant frequencies. Thus, Marrowbone suggests, the differing results were not simply due to the “margin of error.” With regard to how the margin of error should be applied once it has been established, Mr. Blackburn and Marrowbone agree that when two tests fall within the appropriate margin of error, the results more favorable to the claimant should be used to determine his or her level of impairment. Where the difference between two audiograms exceedsthemargin of error, Mr. Blackburn suggests that a third test should be performed by anevaluatoroftheclaimant’sortheDivision’schoosing, while Marrowbone suggests that the Division should be required to refer the claimant for a third audiometric evaluation that would include all tests necessary to ascertain the claimant’s true level of hearing loss, including, but not limited to, brain stem audiometric testing and acoustic reflex testing.10 The Division 9(...continued) vary by as much as 10 dB at some frequencies, but not at all the frequencies tested, and not in the same direction. 10See C.S.R.§ 85-13-4.5, which states: In addition to the routine testing outlined in section 4.4 of thisrule,physiciansevaluating hearing loss claimants should have tympanometry, acoustic reflex and other tests performed, including but not limited to a brain stem audiometry test, any time such tests are needed to reach an informed decision. Brain stem (continued...) 14 opinesthatwhentwoaudiograms differ by more than the accepted margin or error, and both have been performed after the date of last exposure,theevaluatorneedstolookfor a cause other than occupational noise for the decreased hearing levels. Because noise-induced hearing loss is a static condition, the Division maintains that it is inappropriate to use the rule of liberality to choose the higher of two widely-varying audiograms in assigning the level of impairment. 6. Are there any differing expert opinions that have come about since Bilbrey regarding how the “best valid audiogram” is to be determined when all audiograms are reliable and within the margin of error? Mr. Blackburn, Marrowbone and the Division all agree that the medical foundation upon which Bilbrey is based has not changed, and they are aware of no expert opinions contrary toBilbrey regardinghowthe“best valid audiogram” should be determined. 7. What are your recommendations for resolving conflicts in the evidence in work-related hearing loss claims? Mr. Blackburn adopts the recommendation advanced byDr. Gary D. Harris in his deposition in this case. Dr. Harris’ recommendation assumes that 10(...continued) audiometric testing should be performed only when there is suspicion of an acoustic neuroma. (Emphasis added). 15 allaudiogramsunderconsideration are rated reliable and valid, and that they were performed afterthedateoflastexposuretooccupationalnoise. The recommendation also considers each earseparatelyandusesthefour-frequencydecibel sum for500,1000,2000and3000hertz, which are the levels used to calculate whole person impairment under the West Virginia Workers’ Compensation laws. See W.Va.Code§§23-4-6b(b)(1)and(c)(1). Specifically, Dr. Harris suggests: If the four frequency decibel sum differs by 20 dB or less, then such audiograms are probably within the range of normal multiple-audiogram variability and both may represent a claimant’s permanent hearing levels. Using the “worse” audiogram (the one with the highest four-frequency decibel sums) would give the claimant the benefit of the difference. If the four-frequency decibel sum differs by 40 dB or more on two different audiograms, then either some individual frequencies have differed by more than 10 dB, or there has been no interweaving[11]in the two audiograms. Two audiograms with four-frequency decibel sums that vary by 40 dB or more in either ear are significantly different, regardless of the reason for the difference. The better of the two tests, assuming it met all the criteria previously discussed, is a better representation of the claimant’s permanent hearing loss. This leaves then audiograms with four-frequency decibels sums [sic]thatdiffer by morethan20dB,butlessthan40dB. In such instances it would be reasonabletoobtainathirdaudiogram to seeifthemostaccuraterepresentation of a claimant’s permanent occupationally related hearing levels can be determined. Statedsimply,Marrowbonesuggeststhatwheretwoaudiogramsarewithin a 11For a discussion of the term “interweaving,” see supra note 9. 16 marginoferrorofplus or minus five decibels, regardless of whether there is interweaving, 12 theclaimant’sawardshouldbecalculatedfromtheaudiogramthat is most favorable to him or her. Where the difference between two audiograms is between five and ten decibels per frequency,Marrowboneproposesthat additional testing should be performed toobtainan accurate depiction of the claimant’s true hearing level. Finally, where the difference between two audiograms represents a difference that is greater than an average of ten decibels per frequency for the eight measured frequencies in the whole person impairment calculation, then theaudiogramdemonstratingthegreaterdegree of impairment should be discounted so long as: (1) the claimant is no longer exposed to occupational noise; (2) both audiograms were obtainedafter the claimant’s exposure to occupational noise had ceased; and (3) the audiogram showingthelowerdegreeofwholepersonimpairmentwas unequivocally of “good” reliability. Finally, the Division recommends that when two audiograms that are both deemed reliable differ by an amount that is within the accepted margin of error, either audiogram would be appropriate upon which to base a compensation award. In these circumstances, the rule of liberality could be applied to select the audiogram that would provideahigherawardofcompensation. When two reliable audiograms differ by an amount greaterthanthemarginoferror,thentheaudiogramdemonstratingthebestlevelofhearing should be used. However, when two audiograms differ by an amount considerably greaterthan 12For a definition of the term “interweaving” as herein used, see supra note 9. 17 themarginoferror,theprudentcoursewouldbetoperformathirdaudiograminaneffortto determine the most accurate representation of a claimant’s hearing loss. 8. Is noise induced hearing loss progressive or static? The parties agree thatonceexposuretooccupationalnoisehasstopped,occupationalhearinglossbecomesa non-progressive condition. C. Decision Thiscasewasfirstframedassimplyraisingtheissueofwhethertheliberality rule should be applied to Workers’ Compensation hearing loss cases. However, in our considerationofthiscase,itbecame readily apparent that, due to the unique medical nature of hearinglossclaims, the actual issues that needed to be addressed were much more complex, asevidencedbyour decision to direct the parties to file additional briefs addressing specific issuesandtoschedulethiscaseforre-argumentofthoseissues. We previously addressed the uniqueness of hearing loss claims in our decision in Bilbrey v. Workers’ Compensation Commissioner, wherein we observed it is . . . well accepted by experts that once exposure to noise ceases, hearing loss existing at that time must also cease any progression, unless other factors are involved in creating the hearing loss. Damage can be caused by many different factors other than noise, including, but not limited to, diabetes, hypertensionandvasculardiseases,otosclerosis,medications, hereditaryproblems, acoustic trauma, aging (presbycusis), and surgery. We should also note that the audiogram is a subjective test, as it measures a subject’s response to noise. Thus, the 18 reliabilityofthetestand the validity of the results are important factors. [E]xperts have pointed out that if there is a fluctuation in the hearing loss between audiograms which is greater than the margin of error, then the audiogram which shows the least amount of hearinglossshouldbeusedtodeterminethehearinglossdueto noise exposure. The reasoning behind this rule is complicated, butimportant. As we noted above, once noise exposure stops, so doestheprogressionof thehearinglossunlessotherfactorsare involved. Damage to hearing is permanent: Once the hair cells in the cochlea are destroyed, the cells cannot be rejuvenated. Thus, once the damage is done, one’s hearing can get neither betternorworsebecauseofnoiseexposure,butitcangetworse becauseofasecondary condition,such as the conditionslisted above. Thus, if one audiogram shows a substantially worse four frequencytotalthan asecondaudiogram,theexpertmustwork with the premise that since a noise-induced loss is static, some other factor must be responsible for the difference between the two audiograms, such as a sinus or eustachian tube problem. Accordingly, the better audiogram of the two should be used as the audiogram most representative of the sensorineural loss, sincethedifferencebetweenthebestandtheworstaudiograms must be caused by something other than noise. 186 W. Va. at 323-24, 412 S.E.2d at 517-18 (emphasis added) (footnotes omitted). Priorto Bilbrey,therehadbeen“littleornoconsistency in the manner in which theCommissionergrant[ed]permanent partial disability awards for noise-induced hearing impairmentorintheteststhat[were]requiredinordertodeterminewhatpercentageofloss [was] actually due to noise.” 186 W. Va. at 324, 412 S.E.2d at 518. Bilbrey established numerousguidelines in an attempt to correct these inadequacies and to provide a system under which the Division could reach consistent results while also providing a record that would 19 permit this Court a meaningful review. However, Bilbrey stopped short of directing how certain required tests should be performed. 186 W. Va. at 323, 412 S.E.2d at 517 (“[O]ur opinion today does not instruct the physicians how to perform the tests discussed, but instead, advises as to what tests must be performed in order for this Court to reach an informed decision on appeal.”). Throughthisappeal,however,ithasbecomeapparentthatperhapsthe Bilbrey decision should not have been so limited. As this case and Bilbrey exemplify, often two audiograms performed on the same patient will obtain significantly different results. Such differencesmaybetheresult of a variety of factors,not the least of which is the factthatan audiogram is a very subjective test. In Bilbrey, we opined that “if one audiogram shows a substantially worse four frequency total than a second audiogram, the expert must work with the premise that since a noise-induced loss is static, some other factor must be responsible for the difference between the two audiograms, such as a sinus or eustachian tube problem.” 186 W. Va. at 324, 412 S.E.2d at 18. Notwithstanding theBilbrey Court’sexplanationthat“expertshavepointed out thatifthereisafluctuationin the hearing loss between audiograms which is greater than the margin of error, then the audiogram which shows the least amount of hearing loss should be used to determine the hearing loss due to noise exposure,” 186 W. Va. at 323-24, 412 S.E.2d at 517-18 (emphasis added), the Court nevertheless went on to state, in dicta, that 20 wherethedifferencebetween two audiograms was greater than the margin of error, “thebetter audiogram of the two should be used as the audiogram most representative of the sensorineural loss.” Id. at 324, 412 S.E.2d at 518. Thus, by using the phrase “better audiogram”asopposedtoamorespecificphrasereferring to “the audiogram which shows the least amount of hearing loss,” the Bilbrey Court appears to have rejected the expert view in favor of a more neutral procedure. Unfortunately, the Court failed to elaborate on just what it meant by the term “better.” It is also important to note that, while the Division, and to some degree the bar, have apparently interpreted Bilbrey’s explanation of the expert view as a holding,the Bilbrey Courtstoppedshortofcreating any new principleoflawregardinghow todeterminewhichoftwowidely varying, yet apparently valid, audiograms most accurately represents a claimant’s true level of hearing loss. Therefore, we endeavor to do so here. Without minimizing the impact that the subjectivity of audiograms has on the resultsobtained,theevidence presently before this Court suggests that a variety of factors unrelatedtotheclaimant’s condition or cooperation with the testing process may also impact thoseresults. Such factors may include the manner in which the testing is conducted, whether the speech discrimination portion of an audiogram is administered using a monitored live voice orarecordedvoice,themethodsusedtocalibrate the machinery, or perhaps even the type or brand of machinery used. We believe that establishing uniformity with regard to factors such as these would further the goalsBilbrey initiallyidentified,namelyobtainingconsistent results in hearing loss cases and providing for a more meaningful review. Another problem that has 21 come to light in this appeal is the absence of any established margin of error. Without a definitivelysetmarginorerror,therecanbenoassurance of consistency in the application of any rule pertaining to hearing loss claims that utilizes the margin of error. Additionally, we commented in Bilbrey that, because of the subjectivity of audiograms, the reliability and validity of the test results become important factors. 186 W. Va. at 323, 412 S.E.2d at 517 (“The audiogram is a subjective test, as it measures a subject’s response to noise. Thus, the reliability of the test and the validity of the results are important factors.”). The parties to this case, and the experts providing evidence on their behalf, have indicated that while there are numerous methods for judging reliability and validity thatarecommonlyusedwithintheprofession,there exist no specific laws or rules mandating their use, and there is no place provided on the workers’ compensation hearing loss forms to indicate or ascertain their use.13 Requiring that specific reliability and validity measures be 13 Dr. Harris explained in his affidavit that Test/retest threshold reliability has been discussed and studied since the inception of the electronic pure tone test. It has been known since at least 1958 that certain methods of presenting the pure tones to the patient can affect the patient’s responses. Specifically, it has been known since 1958 that comparing thresholds obtained using an ascending stimulus presentation, to thresholds obtained using a descending stimulus presentation can provide an internal reliability check.” (Citation omitted). Dr. Harris further explained that (continued...) 22 utilizedandrecorded, the audiograms would presumptively be more accurate, their reliability could be more effectively monitored by the Division, and the review process would be enhanced. Thus, for the reasons heretofore mentioned, we hold that the Workers’ CompensationDivisionisdirectedtoestablishappropriate guidelines for the specific manner inwhich audiograms should be administered. 14 In developing these guidelines, the Division 13(...continued) Commonly, 1 kHz thresholds are obtained twice with the 1 kHz test threshold expected to be within 5 dB of the 1kHz retest threshold for the ear under test. . . . Providingaplaceontheworkers’ compensation audiogram form forrecordingthetest/retestthresholds at 1kHzwillhelpinsure that such is done. Havingonethresholdsoughtinascending (soft to loud) trials and then the other sought with descending (loud to soft) trials, will enhance the sensitivity of this comparison in determiningreliability(WoodfordC,etal.A screening test for pseudohypacusis. The Hearing Review, No. 1977). Dr. Harris suggests that this information could be elicited from the test audiologist by including a form similar to the following on the audiogram: ascending 1 kHz threshold right ear __ descending 1 kHz threshold right ear __ ascending 1 kHz threshold left ear ___ descending 1 kHz threshold left ear ___ 14It has been explained that: [T]heLegislaturehasdelegatedthe . ..rule-makingfunctionto theCommissionerofthe Bureau of Employment Programs and theWorkers’CompensationDivisionthereof. See W. Va. Code § 23-1-1(b) (2000) (Supp.2001) (“The commissioner is authorizedtopromulgaterulesandregulations to implement the provisionsofthischapter.”);W.Va.Code§21A-2-6(2)(1996) (Supp.2001) (recognizing Commissioner’s authority to (continued...) 23 shouldconsider,inter alia: (1) whether all audiograms should be administered using a uniform brandandmodelofaudiometer;(2)whetherguidelinesshouldbeadopted for when and how audiometers should be uniformly calibrated; (3) establishing a definitive margin of error; (4) requiringaudiologiststoperformspecific reliability and validity checks during the course of anaudiogram;(5) modifying the existing WC-123HL form to allow for the reporting of any requiredreliabilityandvalidity checks; (6) whether the speech discrimination portion of all audiograms should be conducted using only a recorded voice; and (7) what method should be usedtoselectanappropriate audiogram when two audiograms that are both rated “good” differ 14(...continued) “promulgate rules”); Syl. pt. 7, Smith v. State Workmen’s Comp. Comm’r, 159 W. Va. 108, 219 S.E.2d 361 (1975) (“The State Workmen’sCompensation Commissioner may exercise not only thepowersexpresslygrantedtheofficebystatute,butalso such additionalpowers of a procedural or administrative nature as are reasonably implied as a necessary incident to the expressed powers of the office.”). See also W. Va. Code § 23-1-13(a) (1995)(Repl. Vol.1998) (“The workers’ compensation division shalladoptreasonable and proper rules of procedure, regulate and providefor... the nature and extentoftheproofsandevidence, the method of taking and furnishing the same to establish the rights to benefits or compensation from the fund ...or directly from employers . . ., and the method of making investigations, physical examinations and inspections[.]”); W. Va. Code §23-4-6(i)(1999) (Supp.2001) (“The workers’ compensation divisionshalladoptstandards for the evaluation of claimants and thedeterminationofaclaimant’sdegree of whole body medical impairment.”). Repass v. Workers’ Comp. Div., 212 W. Va. 86, ___, 569 S.E.2d 162, 181-82 (2002) (Davis, C.J., dissenting). 24 by more than the established margin of error.15 Recognizingthatitwilltake some time before theseruleswillbeinplace,we endeavor to provide some guidance for the resolution of hearing loss cases involving two differing audiograms in the interim. First, when two audiograms that have both been rated valid 15We recognize that the Division exercises its rule-making function in cooperation with the Health Care Advisory Panel and the Compensation Programs Performance Council: To facilitate the adoption of such rules and regulations for disability determinations, the Legislature authorized the CommissionertocreatetheHealthCareAdvisory Panel to assist withthe“[e]stablish[ment of] protocolsandproceduresforthe performance of examinations or evaluations performed by physicians or medical examiners[.]” W. Va. Code § 23-4-3b(b) (1990)(Repl.Vol.1998). Similarly, the Legislature established theCompensationPrograms Performance Council, W. Va. Code §21A-3-1(1993)(Repl.Vol.1996),[hereinafter referred to as the“PerformanceCouncil”] to further assist the Commissioner with the development of such criteria and to “[r]ecommend legislation and establish regulations designed to ensure the effectiveadministrationandfinancial viability of . . . the workers’ compensationsystemofWestVirginia.” W. Va. Code § 21A-3- 7(b) (1993) (Repl. Vol. 1996). The Performance Council is additionally charged with the “[r]eview and approv[al], reject[ion] or modif[ication of] rules and regulations that are proposed or promulgated by the commissioner for the operation of the workers’compensationsystembeforethefiling of the rules and regulations with the secretary of state.” W. Va. Code § 21A-3- 7(c). Repass,212W.Va.at___, 569 S.E.2d at 182 (Davis, C.J., dissenting). Accordingly, we direct the Division to establish rules with the understanding that it will follow the appropriate statutory requirements in doing so. 25 differsubstantially in their results, it appears to us, based upon the information provided by the parties to this case, that the difference strongly indicates that something other than the claimant’s level of hearing may have impacted the results of one, or perhaps both, of the tests. Underthesecircumstances,particularlyinconsideration of the fact that occupational hearing loss is not a progressive condition once the claimant’s exposure to noise has ended, we believe itwouldbefoolishtoadoptarule directing blind acceptance of the audiogram demonstrating amore significant hearing loss. Indeed, it is well established that the liberality rule does not take the place of proper evidence. In the past, the Court has consistently adhered to the principlethat“theliberalityrulecannotbeconsidered as taking the place of proper and satisfactory proof.” Bilchak v. State Workmen’s Comp. Comm’r, 153 W. Va. 288, 297, 168 S.E.2d 723, 729 (1969). Accord Syl. pt. 3, Clark v. State Workmen’s Comp. Comm’r, 155 W. Va.726,187 S.E.2d 213 (1972); Smith v. State Workmen’s Comp. Comm’r, 155 W. Va. 883, 888, 189 S.E.2d 838, 841 (1972) (per curiam); Syl. pt. 3, Staubs v. State Workmen’s Comp. Comm’r, 153 W. Va. 337, 168 S.E.2d 730 (1969); Dunlap v. State Workmen’s Comp. Comm’r, 152 W. Va. 359, 364, 163 S.E.2d 605, 608 (1968); Hosey v. Workmen’s Comp. Comm’r, 151 W. Va. 172, 176, 151 S.E.2d 729, 731 (1966); Syl. pt. 1, Deverick v. State Comp. Comm’r, 150 W. Va. 145, 144 S.E.2d 498 (1965). Repass v. Workers’ Comp. Div., 212 W. Va. 86, ___, 569 S.E.2d 162, 188-89, (2002) (Davis, C.J., dissenting). Instead, we find the liberality rule should be applied only when two differing audiograms are within the margin of error. Until such time as the Division identifies the 26 margin of error to be applied, a measurement of plus or minus ten decibels shall be used.16 Where two audiograms fall outside this margin, additional testing should be conducted. Accordingly, we hold that until such time as the Division has promulgated additional rules for administering audiograms in workers’ compensation hearing loss cases, when two valid audiograms that have both been performed after the claimant’s date of last exposure to occupationalnoisearewithin a margin of error of plus or minus ten decibels, and do not differ bythesameamountorinthesamedirectionatallfrequencies, the rule of liberality should be appliedandtheclaimant should be granted a permanent partial disability award based upon the audiogramdemonstratingahigherlevelofhearingloss. Additionally, we hold that until such time as the Workers’ Compensation Division has promulgated additional rules for administering audiograms in workers’ compensation hearing loss cases, when two valid audiograms that have both been performed after the claimant’s date of last exposure to 16Marrowbone has agreed with the Division’s position that when two valid audiogramsfallwithinthemarginoferror,thenit is appropriate to apply the liberality rule to grantaclaimantthehigherPPDaward. However, Marrowbone urges that the margin of error should be set at plus or minus five decibels. Our decision to apply a margin of error of plus orminustendecibelsuntilsuchtime as the Division establishes specific rules governing this areaisbasedprimarilyupontheDivision’sobservation that a margin of error of plus or minus tendecibelsisacceptable when comparing audiograms by different audiologists on different machines, due to possible differences in earphone placement and calibration. Because the question of the appropriate margin of error is a matter better suited to the Division’s expertise, we give deference to its opinion in this regard. Cf. Syl. pt. 4, State ex rel. ACF Indus., Inc. v. Vieweg, 204 W. Va. 525, 514 S.E.2d 176 (1999) (“Interpretations as to the meaning and application of workers’ compensation statutes rendered by the Workers’ Compensation Commissioner,asthegovernmentalofficialchargedwith the administration and enforcement of theworkers’compensationstatutorylawofthisState,pursuant to W. Va.Code § 23-1-1 (1997)(Repl.Vol.1998),shouldbeaccordeddeferenceifsuchinterpretations are consistent with the legislation’s plain meaning and ordinary construction.”). 27 occupationalnoisefalloutsideamarginoferrorofplusorminus ten decibels,or are within a margin of error of plus or minus ten decibels but differ in the same amount or in the same direction at all frequencies, then the claimant should undergo additional testing. Presumably thethirdaudiogramwillbewithinamargin of error of ten decibels of one of the existing two audiograms, and will not differ by the same amount or in the same direction at all frequencies, sothattheruleof liberality may be applied to the two audiograms falling within this criteria, and the claimant may be granted a permanent partial disability award based upon the audiogram demonstrating a higher level of hearing loss. If a claimant chooses to have the additional testingperformedbyaphysicianofhisorherchoosing, then the claimant shall pay the expense ofthetesting. If, however, the claimant chooses to have the Division select the examining physician, then the Division shall be responsible for such cost.17 17Theauthorofthisopinion,separatefromthemajority,wishesto clarify that this opinion is not inconsistent with my dissenting opinion in State ex rel.McKenziev.Smith, ___ W. Va.___,___,569S.E.2d809,828(2002). In McKenzie, I criticized the majority for usingtheextraordinaryremedyofmandamustousurp the Workers’ Compensation Division’s discretionary authority to promulgate rules related to vocational rehabilitation by dictating the precise rule that would be imposed. In the instant opinion, however, instead of usurping the Division’sdiscretionaryauthority,wehavemerelydirecteditto exercise that authority, and providedsomeguidancefortheadministrationofhearing loss claims untilsuchtimeasthe Division is able to place its own rules into effect. See, e.g., Bilbrey, 186 W. Va. at 324, 412 S.E.2dat518(“Duringoralargument,counselfortheCommissioner informed this Court that aHealthCareAdvisory Panel has been formed within the Workers’ Compensation office, in which protocols for testing are being established for the various occupational diseases and injurieswhichare subject to dispute before the Workers’ Compensation Fund. Unfortunately, the Panel is not due to address this issue for several months. In the meantime, we believe the Workers’ Compensation Commissioner needs direction in developing a uniform manner of determining the percentage of impairment.”) (Emphasis added). For similar reasons, this opinion is not inconsistent with my dissenting opinion in Repass. 28 V. CONCLUSION Prior to our holding in this case, there existed no settled principals of law guidinghowtoselectwhichaudiogramto use as a basis for a permanent partial disability award when two audiograms both were initially deemed to be valid, but differed by a significant margin. Consequently, because we herein establish temporary guidelines for the resolution of such an occurrence, and because the two audiograms submitted in connection with the instantclaimwerebothinitiallydeemedvalidand differedbyamarginofmorethanplusor minustendecibels,thiscaseisreversedandremandedfor Mr. Blackburn to undergo additional testing. Furthermore, we reiterate to the Division that the guidelines established in this opinion are temporary. Therefore, in directing the Division to establish it’s own rules, in accordance with the appropriate statutory requirements, we further direct the Division to promulgate its rules within a reasonable time. Reversed and Remanded. 29