any cause of connection in this matter as it is against the manifest weight of the evidence and in the event that i am not persuasive to you on this element i'm also here to request that the medical bills awarded by the commission be delineated proper see what the decision of causation is based upon in this case as you're all aware there was quite a bit of medical evidence both in the form of medical records and testimony to the evidence depositions and in this case the arbitrator and the you apply is the case of william gross first is the industrial commission which indicates that an expert's opinion is only as reliable as the facts upon which that opinion is based and if you look at the individual experts in this case upon whom the commission relied and taking them one of the time dr dick was the claimants longtime neurologist dr dick treated the claimant probably for about fifteen years prior to the march first two thousand and seven accident he was well versed at the evidence deposition in the diagnosis of complex regional answer he was well versed in the claim that personal medical history up until that point unfortunately dr  examined her after the march first two thousand and seven accident for complex regional cancer he saw in about seven months after that in the emergency room for what she described as numbness and tingling in her head and then he saw her again when she was seen almost a year later for cellulitis in the hospital he admitted he never evaluated her for complex regional pain syndrome in this case he was complaining of it at that point i'm sorry she wasn't complaining of it at that point she was complaining of other injuries that may have been in the same general vicinity but that was not her complaint that's correct so why would she go beyond that to to see what what the how that might be impacted well he knew what it was he knew what it was and she wasn't complaining that correctly visits that he had with her those two occasions both neither of those were complaints to him about complex regional pain center despite the fact that he had been her a long time physician for that  situation but he did ask the evidence that position provide an opinion relative to cause a connection to opposing counsel in this matter despite the fact that he never of valuated her for complex regional pain syndrome and despite the fact that the history which was provided him by counsel is a variant of that was which testified to you at the time of hearing the claimant is a flight attendant as you're aware she testified at the time of hearing that she was pushing a cart to collect garbage and that a passenger got up and got her way she slipped with both of her legs going under the current she was hanging onto the car what she told the majority of the physicians and what's in the initial medical records is that the current one over ran over her foot those two mechanisms of injury  not compatible with one another i mean if you visualize a car running over your foot one hundred seventy five pound kurdish are evolving on an airline to have the car run over your foot and then have both legs go under the current is mechanically not feasible her statements are inconsistent with one another now whether you believe that the car ran over her foot or what she later testified to and told dr behind ski that they went underneath is is a matter for the commission of sight and i believe that  commission decided that they believed what she testified to on the eve of the hearing that's what is in every decision thereafter so dr dick's opinion though with respect to cause a connection is based upon firstly the fact that the car ran over her foot and secondly that she had complex regional pins and guns and want to bring this up in conjunction with dr lee as well because dr lee did not review any of the records from the time of march first two thousand and seven until the time he saw her in september of syndrome fairly quickly after the original accident in the petitioner in the plaintiff's case typically in her prior medical records they were within about a week's time that she had complex regional pain syndrome after some kind of an incident she had described to be seeing a dog attack and various other incidents which she immediately had onset of symptoms from march first two thousand and seven if you're aug twenty second and the findings were all consistent with the right knee strain which shall see which would be consistent with both like throwing under the car absolutely absolutely and just to be clear  employer is not here to argue a sister as counsel had indicated we're not arguing that there was no accident here i'm doing essentially that she had no manifestation of a complex regional pain syndrome as a result of this accident it's a strict possible connection argument than an incident of pneumonia at the moment hospital which occurs during this timeframe and that goes through all the way through august twenty second two thousand and seven at which point doc has now diagnosed her w and let me make a mention of that shingles issue in conjunction with dr dick's telephone call and may twenty first two thousand and seven she calls dr dick she speaks to his nurse but she says both feet are itching and scale which is why she calls for a medication change so i'm just going to put out there that obviously she has some other processes going on here at the same time as her niece train for which she treated for this six month period of time but nowhere in these initial treatment records either at the moment health or in dr pinocchio's records is there anything consistent with a diagnosis of complex regional hanson room other than the swelling in the knee which is consistent with a new strain and she herself when she goes to berlin hospital on march twelfth two thousand and seven says she was doing fine for the past week she now complains of right lower extremity pain but she says it's different than her complex regional pain syndrome now i'm not going to say that the claimant herself should be held accountable for what her diagnosis is but she certainly had this condition since one nine hundred ninety four and is familiar with what type of symptoms typically are the onset of that problem so for those reasons i would say that dr dick was unfortunately deprived of having any of that history and so his opinion that there is a causal connection opinion without performing at pinnacle exam to determine she in fact had complex regional incident without reviewing any of the records for six months to determine in fact nobody had actually found any clinical findings of complex regional plants and have during that time is simply not reliable with respect to dr levy he not only did not review that timeframe the only information he had about her prior complex regional pain syndrome was the fact that counsel advised him she had a fracture in one thousand nine hundred four which required plate and screws to fixate and then she developed complex regional cancer and so his understanding of her condition was it had completely resolved clearly if you look at the records that had not completely resolved she has onsets all the way through november of two thousand and six documented in medical records here dr pinions should be given no weight because neither of them are based upon any of the facts necessary to make the opinion in this case which brings me to dr pinocchio dr pinocchio is a very nice woman and i think she really cares about  patient and i think she was really trying to help her but that being said i think that the credibility of dr who was at issue during the course of the abbott stuff is ition she tried to testify that there were earlier symptoms of complex regional pain syndrome than actually existed in her clinical records and i cross examination she recanted that testimony when we issued a subpoena for her records we didn't get a complete set of records she blamed that on her clerical staff but these are issues i think with respect to her opinion and she did indicate that she had some understanding of complex regional pain syndrome she's an internist and i'm not saying that she couldn't possibly understand it but it's not documented anywhere in her records that there is anything consistent with complex regional pan syndrome for which she is treating this individual during the first six months of care and after that she abandons all that treatment to dr lee for the medical management so it would be my position that the only credible position in whom you could put any weight in this particular case this doctor wants be who is the employer's examining physician and the reason being he examined her on two separate occasions he reviewed every piece of paper that i could get my hands on which was pretty pretty large amounts of documentation and he took histories from around both of those occasions and i think he had the experience of these other systemic problems the shingles that she developed that monia that she developed or alternatively it just flared up on its own because it has done that in the past and so therefore we are asking that th as you can tell from medical bills a number of them are paid by medicare and i think it's very important for both attorneys that if in fact you continue to find possible connection in this case that the medical bills themselves be delineated and the reason being if medicare decides that something should be paid according to them we have no decision from the commission at this point indicating which dates of service and what amounts are actually do so in the very least i would ask that you remanded to the commission for them to specify those bills and to provide us proper credit for that which was  the simply factual issue this is one which the commission has that is entitle to make decisions about the credibility of the witnesses and to weigh the various facts and draw those terminations as laid out in that counsel has pointed out a number of reasons why each of the treating doctors opinion should not be given weight and address each of those with regard to dr pinocchio family doctor dr testified to an independent recollection of and even though she didn't try to testify that that's what she testified to she was clear that that that she knew i understand that counsel doesn't like the fact that she had a recollection that was over and above what was contained in her medical records but the reality is that's what she testified to and there's no reason to doubt that she did her sitting that her testimony bore that out she clearly knew who an eating gold was  the opinion based upon years of treating anita based upon the facts that were presented to him that this workplace x then did cause an aberration of her  his treatment but he didn't defer opinion and he bases opinion on the information that was provided to him and he testified that he was of that help that opinion to a reasonable degree of medical surgical certainty he had a certain course of treatment but there were also other conditions that he was treating her for and he do any of those for example the foot drop he testified she did not feel was related and there was a different course of treatment the fact that she has multiple conditions does not of the opinion that he had sufficient evidence and information before him to reach that opinion and i understand the position that response counsel said soon but again the doctor believed he had sufficient information to make a diagnosis and to make that opinion and i think that he's entitled to be weighed on that basis in the commission weighed him on that basis and found him to be credible with regard to  lee's opinion i don't believe the doctor julie's testimony was that he believed her condition of aristide had completely gone away he testified that her symptoms were in remission and regularly her symptoms did go in remission there's no doubt the petitioner testified if it's uncontested that she had flare ups of aristide but what's different though about all of the pre prior flare ups from these various years she get that the v c or the dog rider or  whatnot and it would cause her to miss a week of work and the testimony from her doctors and from herself was she struggled to get back to work as quickly as she could at the time of trial on this case she'd been out for thirty months with this where all this was completely different was qualitatively different from any of the of the previous where further dr g lee's opinion is accurate in that she missed five years of work at the time that she had the original injury that injury that of disability had gone away that was resolved and she was working consistently for years with only intermittent flare ups that were of a temporary nature to the i would point to the schieffer case which indicates that when the symptoms are under control and they are under control because she is working on a regular basis yes she has periodic fare but that though they don't preclude her from work for any significant period of time and then the accident happen and that takes her hour and it forces her some stuff that in and of itself is sufficient evidence to demonstrate the causal connection and that's why i cited that particular case is there any contest to the january injury or the earlier injury while i don't believe there's any contest to the accident that injury but as we've argued there was no significant flare up related to that took t t there was awarded was a little over a week perhaps that should be awarded perhaps not if it's to the petitioner that's a relatively minor issue that was a temporary aberration at best that she was back to work within about a week correct that the  there was some discussion about the mechanism but i'm sorry i don't have a hard time visualizing her feet which are in the relates to being run over the same time that her legs are brought underneath the cart in fact she testified that they went under the middle there and so they were dragged under if you were talking about her standing up in the car rolling across her feet that's very different but i don't think that's with actually being described at any point in time  and so i really do think that the commission heard that reviewed the medical records in place the necessary weight and wrote their opinion in that way as far as the onset of symptoms she testified in that commission her to be credible but she stopped working right after this happened she went and she followed the prescribed course of treatment that dr dick had given her for flare ups of her aristid that her fellow fried attendants took over for her and she didn't have to continue working and she went to the doctor that very same day yes she talked about a need because she had a knee injury that was separate from the aristide but she also dr pinocchio testified that there was some signs of swelling and redness and that that certainly could have been a precursor to the flare up of of aristide but for those reasons we believe that the court should have from the decision that has been handed down by the commission and should shingles that the shingles is clearly something different and i don't think there's any medical opinion that connects the two which brings us i suppose to the medical we agree with respond that the medical is not very clearly laid out and it would be helpful for it to be more clearly delineated i think that the parties can probably do the majority of that figuring out based upon what they has been seated so far and based upon a finding that th ose conditions as discussed are not related and therefore those medical bills would not be related with regard to the credit i do want to make a distinction that any credit that's given for any payments made for bills that ultimately are  not chargeable to this claim are not compensable should not be credited against payment for the bills that are compensable if they happen to pay for it if for example doctor the bills for dr doherty who was the infectious disease doctor and those are counsel's contention that dr pinocchio had an independent recollection of this individual i now just during my initial conversation with you that doctor had a personal relationship with this woman and her family she is her family physician and i don't disagree with the fact that she recalled some things with respect to this individual what she specifically stated during her evidence deposition that she did not recall her specific clinical findings she was relying upon her notes to do that so when she attempted to testify to things that were not in her notes that was not her independent recollection that was her attempting to assist her patient with respect to her but occasion and i would ask that this court see that or what it is with respect the claimant had been out for a period of thirty months by the time this case was tried firstly whether a doctor takes somebody off of work i think is completely within that doctor's spectrum but i don't know that that adds  or alleviates their burden of proof with respect to this particular syndrome a complex regional thing was she taken off from work because the doctor just thought it was better for her because she couldn't watch she couldn't do some of the things she needed to do for her employment well i think she was initially taken off of work due to the nice strain that dr pinocchio believed that she had and i think that was reasonable she subsequently developed a number of other conditions which council has conceded are not related including  of which continued she was hospitalized for that cellulitis on two separate occasions these all of which continued to persist with respect to iraq work satis as well as for need for ongoing medical attention so the fact that she was simply off of work for thirty months i don't think you can look at that in a vacuum i think you have to look at what the transaction was between the date of the injury through that entire time frame to determine whether or not you give any credence to the fact that she was off work as far as a chain of events argument and i don't think that counsel's chain of event argument changes the fact that there is no diagnosis of complex regional pain syndrome in that first six months of time that she's off nor are there any clinical findings consistent with  it so and as far as dr dick he indicated that dr dick felt he had enough information to render an opinion i don't think that's what i don't think that is that the doctor gets to decide whether or not he's credible i think that's for the court to