Title: IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: DANIEL DECKER V. STATE OF WYOMING, ex rel., WYOMING MEDICAL COMMISSION and WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION

State: wyoming

Issuer: Wyoming Supreme Court

Document:

IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF:  DANIEL DECKER V. STATE OF WYOMING, ex rel., WYOMING MEDICAL COMMISSION and WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2008 WY 100191 P.3d 105Case Number: S-07-0051Decided: 08/27/2008
APRIL 
TERM, A.D. 2008

 
 
IN 
THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF:  DANIEL 
DECKER,Appellant(Claimant),v.STATE OF 
WYOMING, ex rel., WYOMING MEDICAL COMMISSION and WYOMING WORKERS' SAFETY 
AND COMPENSATION 
DIVISION,Appellees(Respondents).

 
 
Appeal 
from the DistrictCourtofCampbellCounty

The 
Honorable Michael N. Deegan, Judge

 
 

Representing 
Appellant:

Bill 
G. Hibbler of Bill G. Hibbler, P.C., Cheyenne, Wyoming

 
 

Representing 
Appellee:

Patrick 
J. Crank, Wyoming Attorney General; John W. Renneisen, Deputy Attorney General; 
Steven R. Czoschke, Senior Assistant Attorney General; Kristi M. Radosevich, 
Assistant Attorney General

 
 
Before 
VOIGT, C.J., and GOLDEN, HILL, KITE, JJ., and YOUNG, 
D.J.

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

 
 

GOLDEN, 
Justice.

 
 
[¶1]      This appeal is 
round two in Daniel Decker's odyssey to be awarded worker's compensation 
benefits.  Mr. Decker made a claim 
for worker's compensation benefits for an allegedly work related aggravation of 
symptoms associated with thoracic outlet syndrome (TOS).  The Workers' Compensation Division 
denied his claim.  The case was 
referred to the Medical Commission for hearing.  After a hearing before a medical hearing 
panel, the Medical Commission upheld the denial.  

 
 
[¶2]      In the first 
appeal, Worker's Compensation Claim of 
Decker v. State ex rel. Wyoming Medical Comm'n, 2005 WY 160, 124 P.3d 686 
(Wyo. 2005) (Decker I), we vacated 
the Medical Commission's order because it failed to make findings that 
adequately explained the rationale for the Medical Commission's decision.  On remand, without reopening the 
hearing, the Medical Commission entered a new, more detailed order.  Although we find the Medical Commission 
followed proper procedures under the circumstances, we also find that its 
decision is not supported by substantial evidence.   We therefore reverse the denial of 
benefits.

 
 
ISSUES

 
 
[¶3]      Mr. Decker 
presents two issues for our review:

 
 
I.          
Whether the Medical Commission's supplemental order is supported by 
substantial evidence or is arbitrary and capricious in holding that Mr. Decker's 
work did not aggravate his medical condition?

 
 
II.         
Whether the Medical Commission denied Mr. Decker due process by denying 
his attendance and additional argument at the 
deliberation?

 
 
FACTS

 
 
[¶4]      The basic facts 
were set forth in detail in Decker 
I:

 
 
            
Decker began working as a sheet metal worker approximately one year out 
of high school.  He worked for 
Powder River Heating for six and a half years, and then in October 2000 he began 
working for Mountain Aire in Gillette, Wyoming.  
Decker's duties for Mountain Aire were similar to his duties with his 
former employer, except in his employment with Mountain Aire he did not have an 
assistant working with him and he worked more overtime.  His duties included fabrication, 
assembly, and installation of ductwork.  
In the fabrication and assembly processes, Decker's work was performed 
primarily at waist level.  During 
installation of the ductwork, 95% of Decker's work was overhead requiring him to 
work eight hours out of a ten-hour day with his hands over his 
head.

 
 
            
On August 27, 2001, Decker was pulling a piece of tin out from under a 
bench and felt his wrist pop.  
Shortly thereafter while snipping the corners of another piece of tin, 
Decker's other wrist popped and began to feel sore.  From Decker's reported date of injury to 
the date of his hearing before the Medical Commission, Decker was examined 
and/or treated by at least nine physicians and one psychologist, including two 
independent medical examiners.  We 
set forth below a fairly detailed account of the medical evidence presented to 
the Medical Commission . . . .

 
 
            
On August 27, 2001, the same day on which he experienced the onset of 
pain in his wrists, Decker sought medical care from Dr. Paul Johnson.  Dr. Johnson noted his impression that 
Decker suffered from bilateral wrist tendinitis, prescribed a wrist splint for 
his right wrist along with physical therapy, and instructed him to avoid 
grasping and using his grip for extended periods of time.  Dr. Johnson made an entry in his notes 
for that visit that he would see Decker again in one month and "if he is still 
having significant symptoms, and if it acts more neurologic, would then do an 
EMG study."

 
 
            
On August 28, 2001, Decker signed his worker's compensation injury 
report, describing his injury as tendinitis in both wrists.  The Division received the report on 
August 31, 2001.

 
 
            
On September 17, 2001, Decker again saw Dr. Johnson.  Dr. Johnson made the following note 
concerning that visit:

 
 
27-year-old 
male here for recheck of his bilateral hand pain.  He has been going to physical therapy, 
notes that he is a little bit better, however, he has some areas that are a 
little more pronounced in discomfort.  Describes pain radiating back to the 
elbow.  Notes some thumb 
discomfort.  He has pain that goes 
into the middle finger bilaterally.  
His left wrist feels worse than the right.  He notes that on some days he will have 
very little pain and discomfort and then on other days he will have a 
significant amount of paresthesia and pain to the wrist area and fingers.  Notes that he is dropping objects.  He has a hard time with grip 
strength.  Notes occasional lateral 
elbow discomfort.  Denies neck pain 
or shoulder pain.  

 
 
Following 
the September 17, 2001, exam, Dr. Johnson noted his impression that Decker 
suffers from bilateral wrist pain, "suspicious for carpal tunnel syndrome."   He referred him for an EMG study 
bilaterally and instructed him to "continue with work modification, decreased 
usage of his hands, ice, physical therapy modalities."

 
 
            
On October 11, 2001, Decker had a third appointment with Dr. 
Johnson.  Dr. Johnson noted the 
following concerning Decker's condition:

 
 
He 
has bilateral wrist and hand pain with paresthesias.  States lately he has been getting more 
symptoms of paresthesias.  Notes 
when he takes days off and doesn't work he does pretty well however on days that 
he begins working it doesn't take very long for him to begin having the 
paresthesias, pain and weakness.  
Denies elbow or shoulder pain.  
Notes discomfort in all aspects of his hands, pain with 
flexion/extension.  

 
 
Dr. 
Johnson discussed with Decker the results of his EMG test which were 
normal.  Dr. Johnson's overall 
impression of Decker's condition on that visit was "hand paresthesias and 
weakness."  Following the October 
11, 2001, visit, Dr. Johnson referred Decker to Dr. Mark Simonson for an 
evaluation of his paresthesias.

 
 
            
Decker saw Dr. Simonson on October 31, 2001.  Dr. Simonson described Decker as 
presenting "an unusual case of bilateral hand parasthesias, migrating bilateral 
upper extremity pain, sense of discontrol, and an unusual exam." He went on to 
note:

 
 
He 
could have some component of radial tunnel syndrome, though his 
electrodiagnostic study adequately evaluated this possibility and was 
normal.  

 
 
He 
may have some component of thoracic outlet syndrome, noting irritability here, 
with his forward shoulders and tightness throughout the shoulder girdles.  Perhaps he has some degree of underlying 
cervical stenosis.  

 
 
            
* * * *

 
 
I 
am recommending his physical therapist give some attention to the thoracic 
outlet including biomechanics and postural education.

 
 
            
On November 15, 2001, Decker returned to Dr. Simonson for a follow-up 
visit.  Decker reported to Dr. 
Simonson that his overall pain on that date was "not near as bad and has 
improved a lot."   Dr. Simonson 
also made the following note:

 
 
Today, 
he tells me that he gets exhausted by midday.  He tells me that it continually feels 
like his T-shirt is too tight and he is always pulling on it.  He has a sense of fullness in his neck 
and feels like he is not getting enough blood to his head.  He feels borderline dizzy at times.  

 
 
            
* * * *

 
 
This 
continues to appear as a thoracic outlet problem, at least in part.  There may be both neurologic as well as 
vascular components to this.  
Regarding the latter and his complaints of a sense of fullness and poor 
circulation to his head and such, I recommend vascular consultation, with Dr. 
Schabauer.

 
 
            
On December 11, 2001, Decker saw Dr. Schabauer.  According to Decker's testimony, Dr. 
Schabauer's initial examination and testing lasted about one and a half 
hours.  Following that initial 
examination, Dr. Schabauer diagnosed Decker with thoracic outlet syndrome.  His notes concerning his assessment 
provide:

 
 
Thoracic 
outlet syndrome.  Supportive through 
noninvasive testing just completed at the clinic, as well as physical 
examination.  Have recommended that 
he continue with physical therapy, and over the next 6 months, if he does not 
see improvement, could then move onto other considerations.  In the interim, he should also lose 
weight.  This would also help him in 
symptom relief. . . .  Interestingly, it seems with Mr. Decker 
that he has a component of nerve as well as venous and arterial impingement 
present.

 
 
            
In his deposition testimony in this case, Dr. Schabauer testified that 
wrist aching, along with whole arm aching, a degree of numbness and heaviness of 
the arm are symptoms associated with thoracic outlet syndrome.  He also testified that the physiology of 
thoracic outlet syndrome is congenital and he could not say that Decker's work 
caused the condition.  He testified 
further that in his opinion, "based upon a reasonable degree of medical 
probability and/or certainty," Decker's overhead work as a sheet metal worker 
aggravated his thoracic outlet syndrome.

 
 
            
Decker was next referred by Dr. Simonson to Dr. Stephen Annest, a 
vascular surgeon.  On February 19, 
2002, Decker saw Dr. Annest.  Dr. 
Annest diagnosed Decker with brachial plexus impingements, 
noting:

 
 
His 
present complaints are consistent with brachial plexus impingements with pain in 
the shoulder, radiating into the arm and hand with numbness and tingling of the 
ulnar two fingers and thumb.  He has 
a sensation of clumsiness.  Overhead 
actions worsen his symptoms.  

 
 
            
By letter dated March 29, 2002, Dr. Annest provided his opinion that 
Decker's complaints "are work related complaints which resulted from his work as 
a sheet metal worker for Mountain Air Heating Company."  

 
 
            
Decker again saw Dr. Annest on May 7, 2002, still reporting neck, 
shoulder and arm pain.  Dr. Annest 
noted that Decker "continues to have symptoms consistent with a diagnosis of 
brachial plexus entrapment bilaterally," and he referred Decker to Dr. Robert 
Wright at Denver Pain Management for an interscalene block.  Dr. Wright performed the interscalene 
block on May 10, 2002, and noted following the procedure:  "The patient tolerated the procedure 
well and experienced excellent relief of pain in his right upper extremity.  Given the low volume injectate used, 
this result is consistent with and supports a diagnosis of thoracic outlet 
syndrome."  Decker reported that the 
relief of his symptoms following the treatment was only short 
term.

 
 
            
On July 17, 2002, at the Division's direction, Decker saw Dr. Bruce 
Lockwood for an independent medical examination.  Dr. Lockwood included the following 
comments in his notes after examining Decker:

 
 
I 
feel that in all likelihood his intermittent parascapular and cervical pain 
complaints are myogenic in origin.  
This plays a part in what would appear to be myogenic brachial plexus 
irritation at the thoracic outlet. . . . I do feel that his symptoms and with 
the lack of nonorganic dysfunction on exam in all likelihood are produced by 
myogenic thoracic outlet dysfunction.  

 
 
            
* * * *

 
 
I 
feel that there are multiple factors that play a part into why he is having most 
likely a myogenic thoracic outlet syndrome.  These include most importantly probably 
his posture, body mechanics and genetics and his overall systemic 
condition.  Other factors or 
possible aggravators may have been utilization of the activator and activities 
both inside and outside of work which usually are [at] or above chest level and 
are repetitive in nature.  I do not 
feel that a primary injury occurred at work, but do feel that it is reasonable 
and probable that work activities, as well as activities outside of work 
aggravated his overall condition, but did not cause his condition.  

 
 
            
* * * *

 
 
I 
do not feel that his history nor his documentation indicates a work-related 
injury.  The contention is that 
there was a work-related aggravation.  
While I feel that his work activities in all likelihood within a 
probability play a part in his myofascial dysfunction, there are multiple 
factors and more pressing factors outside of work that I have discussed above 
that are playing a part in his presentation.  I also discussed with him my concerns 
that he feels that he was wrongfully terminated or laid off work.  He became somewhat agitated in 
discussing this which indicates there may be actually a significant psychologic 
component or secondary gain issue playing a part in his presentation.  If this continues to persist, a 
psychologic evaluation could help clarify this.

 
 
            
On May 28, 2003, Decker saw another physician, Dr. Charles Brantigan, a 
vascular and thoracic surgeon.  Dr. 
Brantigan noted the following after his physical examination of 
Decker:

 
 
My 
recommendation is that he see a rheumatologist.  The history of joint pains is not 
compatible with thoracic outlet syndrome.  
I have also suggested that he needs to have a CT of the thoracic outlet 
using our protocol.

 
 
The 
problem that we face is that he has no health insurance at the present time. 
 Workmen's Compensation is denying 
his claim.  From my standpoint, it 
sounds like a repetitive motion injury of some type, and absent some other 
explanation, I am inclined to attribute that to his work.

 
 
            
On October 9, 2003, at the Division's direction, Decker saw Dr. Joel L. 
Cohen, a psychologist.  Dr. Cohen 
concluded that Decker was not a good candidate for surgical intervention based 
in part on his following observations:

 
 
He 
is scheduled for a legal hearing in early 2004 and is hoping to find some 
resolve in his situation.  His 
concerns are financial because he has had to pay most of the recent medical 
treatment and as a result has accrued a substantial debt, which [he] is 
struggling to manage.  Given that, 
one has to consider the possibility (whether conscious or unconscious) of 
secondary gain issues.  

 
 
At 
the time of our meeting, the patient was not reporting a substantive injury 
related emotional and psychological distress.  He acknowledged a longstanding history 
of episodic depression. . . . He described himself as often internalizing 
emotional distress and I have no doubt that this is a factor that has 
contributed to the longstanding history of ill health.  To the extent that we can assume his 
internalized emotional distress contributed to previous illness as well as a 
reported history of some colitis-like symptoms it is also clear that we can 
assume internalized distress is an active factor in his current symptom 
complaints.

 
 
            
The last physician Decker saw before his contested case hearing was Dr. 
Gerald Moress, a neurologist.  At 
the Division's request, Decker saw Dr. Moress on January 16, 2004, for another 
independent medical examination.  
Dr. Moress stated that he did not "find any psychological implications" 
for Decker's problem.  His notes 
also stated:

 
 
1.  I am unable to diagnose thoracic outlet 
syndrome either related to occupational exposure or any other causation.  His finding of decreased radial pulse 
with certain provocative measures is found so commonly in the normal population 
that the testing is unreliable.  
There is no gold standard for making the diagnosis of thoracic outlet 
syndrome.  The condition is over 
diagnosed and unfortunately over treated.  
He has aching in both hands and elbows with a bizarre sensory finding of 
decreased perception to pinprick over both palms.  This is clearly nonphysiologic.  There is no evidence of any vascular 
compromise in the upper extremities.  
The motor examination is entirely normal. . . . 

 
 
2.  I agree with Dr. Lockwood that there was 
not any specific injury that occurred at work that caused his symptomology.  He developed nonspecific soft tissue 
muscle ligamentous problems in the upper extremities related to his work. . . 
.

 
 
* 
* * *

 
 
6.  It would be reasonable that his original 
diagnoses had been wrist tendonitis and it certainly would have improved when he 
had discontinued his work.  There is 
no implication for TOS.  

 
 
* 
* * *

 
 
9. 
Mr. Decker's current medical condition is nonspecific discomfort of the forearms 
and hands associated with a nonphysiologic sensory change.  There would be no pre-existing condition 
related to his current complaints.

 
 

Decker 
I, 
¶¶ 3-18, 124 P.3d  at 689-92 (footnotes omitted).  To the above facts, we must note that 
Mr. Decker underwent extensive physical therapy from August 28, 2001, to the end 
of December 2001.  We also note that 
Dr. Johnson issued a work release to Mr. Decker on December 5, 2001.  Despite the work release, Mr. Decker was 
fired from his position on December 11 or 12, 2001, because he was unable to 
return to his former regular schedule.  
His company reported that they let him go because they had no light duty 
work available.  

 
 
[¶5]      The original 
order from the medical hearing panel contained mainly conclusory findings.  The current order more thoroughly 
reflects the evidence and why the medical hearing panel relied almost 
exclusively on the opinions of the doctors performing the independent medical 
examinations.  The medical hearing 
panel denied Mr. Decker's claim in large part because it found Mr. Decker 
unbelievable.  It found Mr. Decker's 
testimony to be "lacking in credibility," and therefore "largely disregarded" 
it.  The hearing panel discounted 
almost entirely the opinions of the treating physicians supporting Mr. Decker's 
claim for benefits because it determined they relied upon "variable and 
contradicting histories given by Mr. Decker,": 

 
 
            
The Panel finds that the physicians who rendered favorable opinions 
regarding Mr. Decker were not in receipt of all, or even most, of the critical 
information and records regarding Mr. Decker.  Such providers were provided with 
minimal records and inaccurate and greatly varying histories by Mr. Decker.  A medical expert can only offer credible 
opinions if they are provided with an accurate history and background.  The history provided by Mr. Decker was 
significantly at variance with the actual history from contemporaneous records, 
and documented facts.  

 
 
In 
the end, the medical hearing panel determined that, "[g]iven Mr. Decker's 
credibility issues, opinions of doctors which rely on his credibility are not 
persuasive." Instead, it "generally agree[d] with the findings by Drs. Lockwood 
and Moress given their ability to conduct an extensive review of Mr. Decker's 
treatment history and their ability to examine him." 

 
 
[¶6]      The medical 
hearing panel summed up its findings:

 
 
The 
Panel finds and concludes that the medical evidence presented not only fails to 
relate Mr. Decker's symptomatology to his employment as a sheet metal worker, 
but even refutes a causal association, either directly or 
indirectly:

 
 
(a)       The initial 
symptoms of wrist pain are consistent with and likely were correctly diagnosed 
and successfully treated as bilateral wrist tendinitis.

 
 
(b)       Wrist 
tendinitis does not cause or lead to thoracic outlet 
syndrome.

 
 
(c)        
Thoracic outlet like symptoms developed and reportedly worsened while he 
was off work or on light duty  not during his regular job duties.  This is exactly the opposite of what 
would be expected, as opined by medical experts.

 
 
(d)       Other 
factors existing at the time periods involved can be incriminated in the 
development of these thoracic outlet symptoms including:

 
 
(i)         
Intrinsic anatomical factors including a slumped posture with forward 
sloping shoulders, and long cervical transverse processes.

 
 
(ii)        
Weight gain.

 
 
(iii)       
Psychological issues including depression very likely contributed to 
multiple symptoms and exaggerated appreciation of 
symptoms.

 
 
(iv)       Other 
aggravating/precipitating factors including working overhead while home 
remodeling and hammering, driving, and overhead and other work at 
Sears.

 
 
DISCUSSION

 
 
Violation 
of due process

 
 
[¶7]      Mr. Decker's 
second issue, by questioning the procedure followed by the Medical Commission 
hearing panel on remand, would prove dispositive of this appeal.  Mr. Decker, in his appellate argument, 
directs our attention to two different facets of the actions of the hearing 
panel on remand that he claims violated his due process rights.  Mr. Decker's arguments raise questions 
of law, which we review de novo.

 
 

Wyoming 
Public Meetings Act

 
 
[¶8]      First, Mr. Decker 
contends that the Medical Commission violated his rights to due process of law 
when the Medical Commission hearing panel assigned to adjudicate his case did 
not deliberate its decision in a public meeting.  Mr. Decker claims this is a violation of 
the Public Meetings Act, Wyo. Stat. Ann. §§ 16-4-401 through 16-4-408, and, 
hence, the review panel's decision is void.  The review panel responded to that 
contention in detail in its Findings of Fact and Conclusions of Law.  The district court gave it short shrift 
in its order affirming the review panel's denial of benefits.  Mr. Decker gave it short shrift in his 
brief in this appeal.  However, if 
his argument is correct with respect to a violation of the Public Meetings Act, 
then the decision is void, and new proceedings must be 
ordered.

 
 
[¶9]      For several 
reasons, we disagree with Mr. Decker's assertion that the hearing panel's order 
is void because it did not comply with Wyoming's Public Meetings Act (PMA).  The PMA was enacted in 1973 and has been 
modified only slightly over the years.  
In the interests of clarity, the provisions of that act are set out 
below:

 
 
§ 
16-4-401. Statement of purpose.

 
 
            
The agencies of Wyoming exist to conduct public business.  Certain deliberations and actions shall 
be taken openly as provided in this act.

 
 
§ 
16-4-402. Definitions.

 
 
(a)  As 
used in this act:

 
 
            
(i)  "Action" means 
the transaction of official business of an agency including a collective 
decision of a governing body, a collective commitment or promise by a governing 
body to make a positive or negative decision, or an actual vote by a governing 
body upon a motion, proposal, resolution, regulation, rule, order or 
ordinance;

            
(ii)  "Agency" means 
any authority, bureau, board, commission, committee, or subagency of the state, 
a county, a municipality or other political subdivision which is created by or 
pursuant to the Wyoming constitution, statute or ordinance, other than the state 
legislature and the judiciary;

            
(iii)  "Meeting" 
means an assembly of at least a quorum of the governing body of an agency which 
has been called by proper authority of the agency for the purpose of discussion, 
deliberation, presentation of information or taking action regarding public 
business;

            
(iv)  "This act" means W.S. 16-4-401 through 
16-4-408.

 
 
§ 
16-4-403. Meetings to be open; participation by public; 
minutes.

 
 
(a)  All meetings of the governing body of an 
agency are public meetings, open to the public at all times, except as 
otherwise provided.  No action of a governing body of an 
agency shall be taken except during a public meeting following notice of 
the meeting in accordance with this act.  
Action taken at a meeting not 
in conformity with this act is null and void and not merely 
voidable.

(b)  A 
member of the public is not required as a condition of attendance at any meeting 
to register his name, to supply information, to complete a questionnaire, or fulfill 
any other condition precedent to his attendance.  A person seeking recognition at the 
meeting may be required to give his name and affiliation.

(c)  Minutes 
of a meeting:

            
(i)  Are required to be recorded but not published from 
meetings when no action is taken by the governing body;

            
(ii)  Are not required to be recorded or published for 
day-to-day administrative activities of an agency. 

 
 
§ 
16-4-404. Types of meetings; notice; recess.

 
 
(a)  In 
the absence of a statutory requirement, the governing body of an agency shall 
provide by ordinance, resolution, bylaws or rule for holding regular meetings 
unless the agency's normal business does not require regular meetings in which 
case the agency shall provide notice of its next meeting to any person who 
requests notice.  A request 
for notice may be made for all future meetings of an 
agency.

(b)  Special meetings may be called by the 
presiding officer of a governing body by giving notice of the meeting to 
each member of the governing body and to each newspaper of general circulation, 
radio or television station requesting the notice.  The notice shall specify the time and 
place of the special meeting and the business to be transacted.  No other business shall be considered at 
a special meeting.

(c)  The governing body of an agency may 
recess any regular, special, or recessed regular or special meeting to a place 
and at a time specified in an order of recess.  A copy of the order of recess shall be 
conspicuously posted on or near the door of the place where the meeting or 
recessed meeting was held.

(d)  The governing body of an agency may hold 
an emergency meeting on matters of serious immediate concern to take temporary 
action without notice.  
Reasonable effort shall be made to offer public notice.  All action taken at an emergency meeting 
is of a temporary nature and in order to become permanent shall be reconsidered 
and acted upon at an open public meeting within forty-eight (48) 
hours.

(e)  Day-to-day administrative activities of 
an agency shall not be subject to the notice requirements of this 
section.

 
 
§ 
16-4-405.  Executive 
sessions.

 
 
(a)  A governing body of an agency may hold 
executive sessions not open to the public:

            
(i)  With the attorney general, county attorney, district 
attorney, city attorney, sheriff, chief of police or their respective deputies, 
or other officers of the law, on matters posing a threat to the security of 
public or private property, or a threat to the public's right of 
access;

            
(ii)  To consider the appointment, employment, right to 
practice or dismissal of a public officer, professional person or employee, or 
to hear complaints or charges brought against an employee, professional person 
or officer, unless the employee, professional person or officer requests a 
public hearing.  The governing body 
may exclude from any public or private hearing during the examination of a 
witness, any or all other witnesses in the matter being investigated.  Following the hearing or executive 
session, the governing body may deliberate on its decision in executive 
sessions;

            
(iii)  On matters concerning litigation to which the governing 
body is a party or proposed litigation to which the governing body may be a 
party;

            
(iv)  On matters of national security;

            
(v)  When the agency is a licensing agency while preparing, 
administering or grading examinations;

            
(vi)  When considering and acting upon the determination of the 
term, parole or release of an individual from a correctional or penal 
institution;

            
(vii)  To consider the selection of a site or the purchase of 
real estate when the publicity regarding the consideration would cause a 
likelihood of an increase in price;

            
(viii)  To consider acceptance of gifts, donations and bequests 
which the donor has requested in writing be kept 
confidential;

            
(ix)  To consider or receive any information classified as confidential by 
law;

            
(x)  To consider accepting or tendering offers concerning 
wages, salaries, benefits and terms of employment during all 
negotiations;

            
(xi)  To consider suspensions, expulsions or other disciplinary 
action in connection with any student as provided by law.

(b)  Minutes shall be maintained of any 
executive session.  Except 
for those parts of minutes of an executive session reflecting a members' 
objection to the executive session as being in violation of this act, minutes 
and proceedings of executive sessions shall be confidential and produced only in 
response to a valid court order.

(c)  Unless 
a different procedure or vote is otherwise specified by law, an executive 
session may be held only pursuant to a motion that is duly seconded and carried 
by majority vote of the members of the governing body in attendance when the 
motion is made.

 
 

§ 
16-4-406.  Disruption of public 
meetings.

 
 
            
If any public meeting is willfully disrupted by a person or group of 
persons so as to render the orderly conduct of the meeting unfeasible, and order 
cannot be restored by the removal of the person or persons who are willfully 
interrupting the meeting, the governing body of an agency may recess the meeting 
and reconvene at another location.  
Only matters appearing on the agenda may be acted upon in a meeting 
recessed to another location.  A 
governing body of an agency shall establish procedures for readmitting an 
individual or individuals not responsible for disturbing the conduct of a 
meeting.  Duly accredited members of 
the press or other news media except those who participated in a disturbance 
shall be allowed to attend any meeting permitted by this 
section.

 
 
§ 
16-4-407. Conflict of law.

 
 
            
If the provisions of this act conflict with any other statute, the 
provisions of this act shall control.

 
 
§ 
16-4-408. Penalty.

 
 
(a)  Any 
member or members of an agency who knowingly and willfully takes an action in 
violation of or conspires to take an action in violation of this act shall be 
guilty of a misdemeanor.  Any member 
of the governing body of an agency who attends or remains at a meeting where an 
action is taken knowing that the action is in violation of this act shall be 
guilty of a misdemeanor unless minutes were taken during the meeting and the 
parts thereof recording the member's objections are made public or at the next 
regular public meeting the member objects to the meeting where the violation 
occurred and asks that the objection be recorded in the minutes.  Either misdemeanor violation under this 
subsection is punishable upon conviction by a fine of not more than seven 
hundred fifty dollars ($750.00).

(b)  If 
any action is prohibited both by this act and any provision of title 6, the 
provisions of this act shall not apply and the provisions of title 6 shall 
apply.

 
 
Wyo. 
Stat. Ann. §§ 16-4-401 through 16-4-408 (LexisNexis 2007) (emphasis 
added).

 
 
[¶10]   Prior to 1986, disputed worker's 
compensation cases were adjudicated in the district courts.  In 1986, the Wyoming Legislature changed 
that process to the use of independent hearing officers, with appeals available 
to both the district courts and the Supreme Court.  1986 Wyo. Sess. Laws (Special Session) ch. 3.  This change was formalized in 1992, when 
the office of administrative hearings was created.  1992 Wyo. Sess. Laws ch. 30.

 
 
[¶11]   In 1993, in recognition of an 
apparent need for a specialized, quasi-judicial hearing body to consider 
worker's compensation cases that required hearing officers with medical 
expertise, the Wyoming Legislature created the Medical 
Commission:

 
 
§ 
27-14-616. Medical commission; hearing panels; creation; membership; duties; 
rulemaking.

 
 
(a)  The 
medical commission is created to consist of eleven (11) health care providers 
appointed by the governor as follows:

            
(i)  Seven (7) licensed physicians appointed from a list of not 
less than fourteen (14) nominees submitted by the Wyoming Medical 
Society;

            
(ii)  Four (4) health care providers appointed from a list of 
not less than eight (8) nominees developed and submitted by appropriate health 
care provider groups selected by the director.

(b)  One 
(1) member shall be elected by commission members as chairman and one (1) as 
vice-chairman.  The division shall 
designate an employee to serve as executive secretary of the commission or 
contract with an individual to provide executive secretary services to the 
commission.  The governor may 
appoint no more than eleven (11) additional health care providers as associate 
members of the commission whose function is limited to serving as members of 
individual medical hearing panels.  
Except for initial members, the terms of commission members and associate 
members shall be three (3) years.  
Three (3) members of the initial commission and three (3) initial 
associate members shall be appointed to a one (1) year term and four (4) initial 
commission members and four (4) initial associate members shall be appointed to 
a two (2) year term.  The duties of 
the commission shall be:

            
(i)  To promulgate rules and regulations, with the approval of 
the director of the department, declaring particular medical, hospital or other 
health care procedures either acceptable or not necessary in the treatment of 
injuries or particular classes of injuries and therefore either compensable or 
not compensable under this act or expanding or limiting the compensability of 
such procedures under this act;

            
(ii)  To promulgate rules and regulations, with the approval of 
the director of the department, establishing criteria for certification of 
temporary total disability by health care providers and setting forth the types 
of injuries for which particular health care providers may certify temporary 
total disability pursuant to W.S. 27-14-404(g);

            
(iii)  To advise the division, upon request, on the usefulness 
of medical cost containment measures; and

            
(iv)  To furnish three (3) members of the commission to serve 
as a medical hearing panel to hear cases referred for hearing.  The division shall refer medically 
contested cases to the commission for hearing by a medical hearing panel.  The decision to refer a contested case 
to the office of administrative hearings or a medical hearing panel established 
under this section shall not be subject to further administrative review.  Following referral by the division, the 
hearing examiner or medical hearing panel shall have jurisdiction to hear and 
decide all issues related to the written notice of objection filed pursuant to 
W.S. 27-14-601(k).  Different 
medical hearing panels with different membership may be selected to hear 
different cases, but a panel may hear more than one (1) case.  Individual medical hearing panels shall 
be selected by the executive secretary under the supervision and guidance of the 
chairman of the medical commission.  
At least one (1) member of each panel shall be a physician.  One (1) member shall be designated by 
the executive secretary to serve as chairman of the panel.  When hearing a medically contested case, 
the panel shall serve as the hearing examiner and shall have exclusive 
jurisdiction to make the final administrative determination of the validity and 
amount of compensation payable under this act.  For cases referred to the medical 
commission as small claims hearings under W.S. 27-14-602(b), the medical hearing 
panel may consist of one (1) physician who shall serve as the hearing examiner 
and shall have exclusive jurisdiction to make the final administrative 
determination of the validity and amount of compensation payable under this 
act.

(c)  The 
members of the commission and of medical hearing panels when serving shall be 
immune from liability and shall be defended by the attorney general if sued and 
indemnified against loss from legal action in the same manner as state 
employees.

(d)  The 
division shall establish a fee schedule for the compensation of members of the 
medical commission and medical hearing panels for their professional services to 
be paid from the worker's compensation account.

(e)  Upon 
agreement of all parties to a case, the hearing examiner in a contested case 
under this chapter may transfer a medically contested case to a medical hearing 
panel or may seek the advice of the medical commission on specified medical 
issues in the contested case.  The 
advice shall be in writing and shall become part of the record of the 
case.

 
 

Wyo. 
Stat. Ann. § 27-14-616 (LexisNexis 2007).

 
 
[¶12]   Wyo. Stat. Ann. § 27-14-602(b)(ii) 
(LexisNexis 2007) (emphasis added) provides:

 
 
            
(ii)  All other requests for hearing not specified under 
paragraph (b)(i) of this section shall be conducted as a contested case in 
accordance with procedures of the Wyoming Administrative Procedure Act and the 
Wyoming Rules of Civil Procedure as applicable under rules of the office of 
administrative hearings.  The 
hearing examiner designated by the office of administrative hearings shall 
render a decision in a contested case within thirty (30) days after the close of 
the record.  If the contested case 
is heard by the hearing panel created pursuant to W.S. 27-14-616(b)(iv), the panel shall render a decision within 
forty-five (45) days after the close of the record; . . . 
.

 
 
[¶13]   All other worker's compensation 
case disputes are resolved before hearing examiners, which were created in 1992, 
as established in the following legislation:

 
 
§ 
9-2-2201. Office created; appointment of director and hearing 
examiners.

 
 
(a)  The 
office of administrative hearings is created as a separate operating agency 
pursuant to W.S. 9-2-1704(d).

(b)  The 
governor, with the advice and consent of the senate, shall appoint a director of 
the office who shall serve as the administrative head of the office and as chief 
hearing examiner.  Unless sooner 
removed, the director's term of appointment expires at the end of the term of 
office of the governor during which he was appointed.  The director serves at the pleasure of 
the governor and may be removed by him as provided by W.S. 9-1-202.  The director shall be a member in good 
standing of the Wyoming state bar.

(c)  The 
director may appoint additional hearing examiners who are members in good 
standing of the Wyoming state bar to serve either full or part 
time as necessary throughout the state.  
Hearing examiners serve at the pleasure of the director and may be 
removed by him at any time without cause.

 
 
§ 
9-2-2202. Duties and function of office.

 
 
(a)  The 
office of administrative hearings is the successor agency to the office of 
independent hearing examiners created by W.S. 27-14-602 and the office of 
hearing examiners created by W.S. 31-7-105.  Effective July 1, 
1992:

            
(i)  There is transferred to the office of administrative 
hearings all positions, personnel, property and appropriated funds of the office 
of independent hearing examiners and the office of hearing 
examiners;

            
(ii)  The office of administrative hearings shall assume all 
duties and responsibilities and exercise all authority of the office of 
independent hearing examiners and the office of hearing examiners set out in 
title 27, chapter 14 and title 31, chapters 6, 7, 9 and 17 of the Wyoming 
statutes.

(b)  In 
addition to conducting hearings pursuant to subsection (a) of this section, the 
office of administrative hearings may, if requested, provide hearing services 
for any other state agency, provided:

            
(i)  Hearing services shall be provided to other agencies 
subject to available resources;

            
(ii)  The cost of the hearing services as determined by the 
director of the office of administrative hearings shall be paid by the 
requesting agency to the office of administrative 
hearings;

            
(iii)  Hearings will be conducted in an impartial manner 
pursuant to the Wyoming Administrative Procedure Act, applicable provisions of 
the Wyoming Rules of Civil Procedure and any rules for the conduct of contested 
cases adopted by the director of the office of administrative hearings which 
shall take precedence over hearing rules promulgated by the requesting 
agency.  In the case of personnel 
hearings conducted pursuant to W.S. 9-2-1019, the state personnel rules shall 
govern the conduct of the hearings;

            
(iv)  Hearings may be held in any area of the state giving 
consideration to the resources of the office of administrative hearings and the 
convenience of the parties. 

 
 

Wyo. 
Stat. Ann. §§ 9-2-2201 and 9-2-2202 (LexisNexis 2007).

 
 
[¶14]   Hearing examiners also perform 
quasi-judicial functions.  Whether a 
case is before a hearing examiner or before a hearing panel assigned by the 
Medical Commission for a particular case, the trial-type proceedings are about 
the same.  All testimonial evidence 
and all trial proceedings are taken down verbatim by a court reporter.  All documentary evidence is included in 
the record.  The hearing examiner or 
Medical Commission hearing panel is required to issue a detailed order which 
contains a complete recitation of the finding of facts it made and the 
conclusions of law it reached.  See, e.g., Decker I, ¶¶ 25-28, 124 P.3d  at 
694-95.

 
 
[¶15]   Some of our most important 
principles of statutory construction apply to the analysis of this 
issue:

 
 
In 
interpreting statutes, our primary consideration is to determine the 
legislature's intent.  All statutes 
must be construed in pari materia 
and, in ascertaining the meaning of a given law, all statutes relating to the 
same subject or having the same general purpose must be considered and construed 
in harmony.  Statutory construction 
is a question of law, so our standard of review is de novo.  We endeavor to interpret statutes in 
accordance with the legislature's intent.  
We begin by making an inquiry respecting the ordinary and obvious meaning 
of the words employed according to their arrangement and connection.  We construe the statute as a whole, 
giving effect to every word, clause, and sentence, and we construe all parts of 
the statute in pari materia.   When a statute is sufficiently 
clear and unambiguous, we give effect to the plain and ordinary meaning of the 
words and do not resort to the rules of statutory 
construction.

 
 

BP 
America Prod. Co. v. Dep't of Revenue, State of Wyo., 
2005 WY 60, ¶ 15, 112 P.3d 596, 604 (Wyo. 2005).

 
 
[¶16]   Moreover:

 
 
We 
presume that statutes are enacted by the legislature with full knowledge of 
existing law, so we construe statutes in harmony with existing law, particularly 
other statutes relating to the same subject or having the same purpose. . . 
.

 
 
            
Statutes must be construed so that no portion is rendered meaningless. . 
. . Interpretation should not produce an absurd result. . . . We are guided by 
the full text of the statute, paying attention to its internal structure and the 
functional relation between the parts and the whole. . . . Each word of a 
statute is to be afforded meaning, with none rendered superfluous. . . . 
Further, the meaning afforded to a word should be that word's standard popular 
meaning unless another meaning is clearly intended. . . . If the meaning of a 
word is unclear, it should be afforded the meaning that best accomplishes the 
statute's purpose. . . .We presume that the legislature acts intentionally when 
it uses particular language in one statute, but not in another. . . . If two 
sections of legislation appear to conflict, they should be given a reading that 
gives them both effect.

 
 

Hede 
v. Gilstrap, 
2005 WY 24, ¶ 6, 107 P.3d 158, 163 (Wyo. 2005) (quoting Rodriguez v. Casey, 2002 WY 111, ¶¶ 
9-10, 50 P.3d 323, 326-27 (Wyo. 2002)).

 
 
[¶17]   There are many bases upon which 
this Court might conclude that the Medical Commission hearing panels are not 
required by the PMA to permit parties or the public to sit in on their 
deliberations.  To begin with, a 
Medical Commission hearing panel is not an "agency" as that word is used in the 
PMA.  An "agency" is defined as "any 
authority, bureau, board, commission, committee, or subagency of the state, a 
county, a municipality or other political subdivision which is created by or 
pursuant to the Wyoming constitution, statute or ordinance, 
other than the state legislature and the judiciary."  § 16-4-402(ii).  Individual medical hearing panels do not 
fit within this definition.  They 
are impermanent bodies not created by the legislature.  Certainly the legislature has provided 
for their potential existence, but their actual existence is governed solely by 
the Medical Commission.

 
 
[¶18]   The legislature created the Medical 
Commission and empowered it to assemble medical hearing panels solely as 
necessary to hear medically contested worker's compensation cases.  "Different medical hearing panels with 
different membership may be selected to hear different cases." § 
27-14-616(b)(iv).  Indeed, the 
Medical Commission attempts to individualize panels by appointing commission 
members with expertise relevant to the circumstances of the case being 
heard.  Wyo. Dep't of Employment, 
Workers' Compensation, Medical Commission Rules & Regulations, ch. 6, § 1(b) 
(Feb. 14, 2003).1  As a consequence, potentially, multiple 
medical hearing panels may exist at any given time.  Equally, it is possible that there might 
be a time when no medical hearing panel exists because there are no outstanding 
medically contested cases to be heard.  
A medical hearing panel, being a transitory body, and existing and 
operating exclusively under the auspices of the Medical Commission, does not 
fall within the definition of "agency" as used in the PMA.   

 
 
[¶19]   Moreover, even if a Medical 
Commission hearing panel were to be considered an "agency," a decision by the 
panel is not an "action" as that word is used in the PMA.  A hearing panel is not a "governing 
body" as that phrase is used in the PMA.  
A quasi-judicial hearing conducted by a hearing panel is not a "meeting" 
as that word is used in the PMA.  
Finally, as noted above, a hearing panel may deliberate for forty-five 
days and then its decision must be forthcoming in written form.  It makes no sense to read the PMA so as 
to require a hearing panel to curtail its deliberative process to a few minutes 
at a quasi-judicial hearing, when the statutes that created those hearing panels 
contemplated that they may deliberate over a period of forty-five days after 
pondering the often voluminous and very technical medical testimony and records 
that make up the evidence at such quasi-judicial hearings.  Because a Medical Commission hearing 
panel is not an "agency" and its decisions are not "actions" as defined by the 
PMA, the hearing panels are not subject to the strictures of the 
PMA.

 
 
Presentation 
of Additional Evidence

 
 
[¶20]   Mr. Decker also suggests the 
Medical Commission violated his due process rights on remand by not allowing him 
to present additional evidence.  Mr. 
Decker's due process rights, however, were not implicated by the procedure used 
in this case.  Mr. Decker had a full 
and fair opportunity to present his case during his hearing.  

 
 
[¶21]   On remand after Decker I, our mandate did not require 
the case be reopened to allow additional evidence.  It only required the Medical Commission 
enter a new order more thoroughly explaining the reason for its denial of 
benefits based on the evidence adduced at the hearing so we could rationally 
review its decision.  

 
 
[¶22]   Mr. Decker argues that, in Decker I, we heightened his burden of 
proof and therefore he must be allowed to enter new evidence to meet that 
burden.  Mr. Decker, however, 
conveniently misreads our discussion in Decker I.  As we made clear in that discussion, we 
were simply identifying Mr. Decker's theory of his case as he presented it 
before the medical hearing panel.2  We altered nothing.  Mr. Decker seems to be opportunistically 
attempting to get a second bite at the apple.  The refusal by the Medical Commission to 
allow him his second bite certainly raises no due process 
concerns.

 
 
Substantial 
Evidence

 
 
[¶23]   In an appeal from a district 
court's decision on a petition for review of administrative action, we afford no 
deference to the district court's decision.  Rather, we review the case as if it came 
directly from the agency.  McIntosh v. State ex rel. Wyoming Medical 
Comm'n, 2007 WY 108, ¶ 8, 162 P.3d 483, 487 (Wyo. 2007); Wright v. State ex rel. Wyoming Workers' 
Safety and Comp. Div., 2007 WY 101, ¶ 6, 160 P.3d 1129, 1131 (Wyo. 2007); Bonsell v. State ex rel. Wyo. Workers' 
Safety and Comp. Div., 2006 WY 114, ¶ 7, 142 P.3d 686, 688 (Wyo. 2006).  As in all administrative proceedings, 
our review is limited by Wyo. Stat. Ann. § 16-3-114(c) (LexisNexis 2007) 
to:

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

 
 
* 
* * *

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

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

 
 
            
* * * *

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

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

 
 
We 
do not defer to the agency's determination on issues of law; instead, we will 
correct any error made by the agency in either interpreting or applying the 
law.  McIntosh, ¶ 8, 162 P.3d  at 
487.

 
 
[¶24]   Mr. Decker argues the decision of 
the Medical Commission denying him benefits is not supported by substantial 
evidence.  In reviewing findings of 
fact, we examine the entire record to determine whether there is substantial 
evidence to support an agency's findings.  
Substantial evidence is relevant evidence which a reasonable mind might 
accept in support of the agency's conclusions.  It is more than a scintilla of evidence 
but can be less than the weight of the evidence.  Decker I, ¶ 23, 124 P.3d  at 694; Wyoming Consumer Group v. Public Service 
Comm'n of Wyoming, 882 P.2d 858, 860-61 
(Wyo. 1994); Montana Dakota Utilities Co. v. Public Serv. 
Comm'n, 847 P.2d 978, 983 (Wyo. 1993).

 
 
[¶25]   The Medical Commission's decision 
essentially is that the initial diagnosis of wrist tendonitis was correct and 
the condition completely resolved within a few months.  The primary evidentiary support for this 
conclusion is the original diagnosis by Dr. Johnson of wrist tendonitis and Dr. 
Johnson's unconditional work release on December 5, 2001.  The Medical Commission also finds the 
physical therapy notes from October to December 2001 support their conclusion 
that Mr. Decker's wrist tendonitis had resolved by early December.  Finally, the Medical Commission relies 
upon the findings of Dr. Moress in his IME, specifically finding number six 
relating Mr. Decker's original complaints to wrist tendonitis and opining the 
tendonitis would certainly have improved with time off work.  

 
 
[¶26]   This evidence, when viewed in the 
context of the record as a whole, is not substantial.  Given the Medical Commission's theory of 
the case, the key question in this case is whether Mr. Decker's original 
symptoms were caused by wrist tendonitis or were symptoms of TOS.  One fact the Medical Commission noted to 
support a diagnosis of wrist tendonitis instead of TOS was that, although 
working overhead is a known TOS aggravator, Mr. Decker did not develop symptoms 
immediately upon beginning work as a sheet metal worker, but rather over seven 
years later.  This factor, however, 
is not necessarily significant to his TOS diagnosis in 2001.  According to the deposition testimony of 
Dr. Schabauer, the physiology making a person susceptible to TOS may be present, 
indeed it could be considered a congenital condition, but symptoms are not 
always present. 

 
 
[¶27]   Another fact noted by the Medical 
Commission is that Mr. Decker's wrist pain began when he was working at waist 
level or below.  Dr. Schabauer, who 
had Dr. Moress' IME report at the time of his deposition, was aware of this fact 
but it did not prevent him from diagnosing TOS attributed to Mr. Decker's work 
effort.  Dr. Lockwood also was aware 
of the nature of the onset of symptoms yet he too agreed Mr. Decker suffered 
from TOS and his work effort aggravated his condition.

 
 
[¶28]   Then there is Dr. Johnson's initial 
diagnosis of wrist tendonitis.  
However, when the complete notations from that first exam are read, they 
indicate Dr. Johnson's diagnosis of wrist tendonitis was not a definitive 
diagnosis but rather a differential diagnosis.  Dr. Johnson wanted to see Mr. Decker 
again if physical therapy and other measures did not help and Mr. Decker was 
still symptomatic.  Dr. Johnson made 
his initial diagnosis of wrist tendonitis on August 27, 2001.  On September 17, 2001, at Mr. Decker's 
next visit, Dr. Johnson abandoned his diagnosis of wrist tendonitis. On 
September 28, 2001, a physical therapist administered tests to Mr. Decker and 
found no signs of wrist tendonitis.  
During the search for a new diagnosis that involved at least five other 
doctors, there was no further mention of the possibility of wrist 
tendonitis.

 
 
[¶29]   The evidence supporting a finding 
that Mr. Decker's original complaints were symptoms of TOS is overwhelming.  Dr. Schabauer testified at his 
deposition that symptoms of TOS include wrist aching, whole arm aching, a degree 
of numbness, and heaviness of the arm.  
A chronological review of Mr. Decker's medical records, including his 
physical therapy records, indicates that Mr. Decker consistently complained of 
wrist and hand pain, pain radiating to the elbow, hand weakness and 
numbness.  He complained of pain 
radiating into his elbow and hand weakness his first visit with Dr. Johnson on 
August 27, 2001.  He complained of 
pain, weakness and numbness during his evaluation by the physical therapist the 
next day.  The physical therapist 
found Mr. Decker showed "significant decrease in both strength and sensation in 
bilateral wrists and hands" and experienced "pain with overpressure in right 
elbow extension."  During his 
examination with Dr. Johnson on September 17, Mr. Decker continued to have the 
same complaints: "He notes that on some days he will have very little pain and 
discomfort and then on other days he will have a significant amount of 
paresthesia and pain to the wrist area and fingers."  Mr. Decker also mentioned to Dr. Johnson 
that he was "dropping objects" and he "experiencing pain radiating back to the 
elbow."  These symptoms fit well 
within the rubric of TOS.  We find 
the symptoms related from the beginning by Mr. Decker were symptoms of TOS and 
not wrist tendonitis.

 
 
[¶30]   The remaining question is whether 
Mr. Decker has adequately proven his TOS symptoms were caused by his work 
effort.  The causal connection 
between an accident or condition at the workplace is satisfied if the medical 
expert testifies that it is more probable than not that the work contributed in 
a material fashion to the precipitation, aggravation or acceleration of the 
injury:

 
 
We 
do not invoke a standard of reasonable medical certainty with respect to such 
causal connection.  Kaan v. State ex rel. Wyoming Worker's Compensation Div., 689 P.2d 1387, 
1389 (Wyo. 1984) (citing Jim's Water Service v. Eayrs, 590 P.2d 1346 (Wyo. 
1979)).  Testimony by the medical 
expert to the effect that the injury "most likely," "contributed to," or 
"probably" is the product of the workplace suffices under our established 
standard.   Kaan, 689 P.2d  at 1389. 

 
 

In 
re 
Pino, 996 P.2d 679, 685 (Wyo. 
2000).  See Huntington v. State ex rel. Wyoming 
Workers' Comp. Div., 2007 WY 124, ¶ 11, 163 P.3d 839, 842 (Wyo. 2007); Ramos v. State ex rel. Wyoming Workers' 
Safety and Comp. Div., 2007 WY 85, ¶ 18, 158 P.3d 670, 677 (Wyo. 
2007).

 
 
[¶31]   The Medical Commission concluded 
that Mr. Decker's work effort was not a materially aggravating factor in his TOS 
for two primary reasons: the symptoms did not begin until after he had been 
working for over seven years; and the symptoms did not improve after he quit 
working.  The first issue is best 
answered by addressing factors that had changed in Mr. Decker's life that may 
have precipitated the onset of symptoms in 2001.  The most obvious change for our purposes 
is his change in employment.  Mr. 
Decker's new employment required him to work longer hours without an 
assistant.  The result was much 
greater overhead exertion, a known aggravating factor for TOS.  The Medical Commission relied on other 
aggravating factors as well, such as poor posture and an unknown increase in 
weight prior to the onset of his wrist pain.  However, it must be remembered we do not 
weigh possible aggravating factors.  
Decker I, ¶ 40, 124 P.3d at 
698-99; In re Boyce, 2005 WY 9, ¶ 11, 
105 P.3d 451, 455 (Wyo. 2005) (there is no authority requiring a medical expert 
to apportion the aggravation between work conditions and other possible 
contributing factors).  

 
 
[¶32]   The second issue also brings into 
question the possible existence of other aggravating factors.  Again, the only question is whether Mr. 
Decker's employment was a material aggravating factor, in and of itself, in Mr. 
Decker's condition.  The issue was 
addressed by Dr. Schabauer in his deposition.  He testified that symptoms of TOS change 
over time.  While symptoms can be 
debilitating when a person is engaged in materially aggravating activity, such 
as working overhead, TOS symptoms can also be elicited with fairly simple 
activities.  Most importantly, he 
testified that, even if a person suffering from TOS does everything correctly, 
"uniformly people with thoracic outlet do not become 100 percent better."   We find the import of Dr. 
Schabauer's testimony to be that the progression of symptoms of TOS are 
unpredictable.  We therefore find 
the heavy reliance by the Medical Commission on what they deem to be an increase 
in symptoms for the purpose of determining causation to be lacking in 
evidentiary support.3

 
 
[¶33]   Finally, and most importantly, 
several doctors opined that the repetitive overhead exertion required of Mr. 
Decker in his job was an aggravating factor in his complaints.  The Medical Commission decided to 
discount the opinions on causation of Mr. Decker's treating physicians because 
they did not have all the relevant, accurate patient history.  We disagree with this conclusion as it 
regards Dr. Schabauer.  At the time 
of his deposition, Dr. Schabauer had received and reviewed a copy of Dr. Moress' 
IME report.  Thus, he had a review 
of the complete medical history of Mr. Decker.  Even after receiving that information, 
Dr. Schabauer continued to opine that Mr. Decker suffered from TOS, which was 
aggravated by his overhead work activities. 

 
 
[¶34]   In any event, the Medical 
Commission's credibility determination does not apply to Dr. Lockwood.  Dr. Lockwood performed the first IME on 
Mr. Decker in July 2002.  As the 
Medical Commission stated, Dr. Lockwood had all the medical records from 
previous treating physicians.  After 
reviewing the records, and examining Mr. Decker, Dr. Lockwood opined that Mr. 
Decker suffered from TOS and "that it is reasonable and probable that work 
activities  aggravated his overall condition." 

 
 
CONCLUSION

 
 
[¶35]   The Medical Commission followed the 
proper procedures on remand from Decker 
I.  The Public Meetings Act did 
not require the Medical Commission to allow Mr. Decker to attend new 
deliberations as argued by Mr. Decker.  
There was also no requirement for the Medical Commission to reopen the 
hearing for the taking of additional evidence.  The Medical Commission was well within 
its discretion to simply enter a new, more thorough order explaining its 
position and the reasons therefore.

 
 
[¶36]   The decision of the Medical 
Commission denying benefits to Mr. Decker for a work-related aggravation of 
symptoms related to TOS is not supported by substantial evidence when viewed on 
the record as a whole.  The order 
denying benefits is hereby reversed.  
This case is remanded for further proceedings consistent with this 
opinion.

 
 
KITE, 
J., dissenting, in which VOIGT, C.J., joins.

 
 
[¶37]   I dissent from the majority opinion 
because I believe Wyoming's Public Meetings Act, Wyo. Stat. Ann. § 16-4-401, et 
seq. (LexisNexis 2007), applies to the deliberations of Medical Commission 
panels and the panel in this case violated the law when it closed its 
deliberations to the public.  The 
Public Meetings Act requires:

 
 
(a)  All meetings of the governing body of an 
agency are public meetings, open to the public at all times, except as otherwise 
provided.  No action of a governing 
body of an agency shall be taken except during a public meeting following notice 
of the meeting in accordance with this act.  Action taken at a meeting not in 
conformity with this act is null and void and not merely 
voidable.

 
 
Section 
16-4-403(a).  The following 
definitions help delineate the scope of the Public Meetings 
Act:

 
 
(i) 
"Action" means the transaction of official business of an agency including a 
collective decision of a governing body, a collective commitment or promise by a 
governing body to make a positive or negative decision, or an actual vote by a 
governing body upon a motion, proposal, resolution, regulation, rule, order or 
ordinance;

 
 
(ii) 
"Agency" means any authority, bureau, board, commission, committee, or subagency 
of the state, a county, a municipality or other political subdivision which is 
created by or pursuant to the Wyoming constitution, statute or ordinance, other 
than the state legislature and the judiciary;

            

(iii)  "Meeting" means an assembly of at least 
a quorum of the governing body of an agency which has been called by proper 
authority of the agency for the purpose of discussion, deliberation, 
presentation of information or taking action regarding public 
business[.]

 
 
Section 
16-4-402(a).  The majority opinion 
concludes that the Public Meetings Act does not apply to deliberations of the 
Medical Commission panels because an individual panel is not an "agency."     

 
 
[¶38]   In order to determine whether 
Medical Commission panels fall within the definition of "agency" for application 
of the Public Meetings Act, we look to the statutes pertaining to the Medical 
Commission.  The Medical Commission 
exists by authority of the legislature, and its members are appointed by the 
governor.  Wyo. Stat. Ann. § 
27-14-616 (LexisNexis 2007).  The 
Medical Commission is authorized to promulgate its own rules and regulations 
under the Administrative Procedure Act.  
Id.  
See also, § 16-3-102; Rules and Regulations of the Medical 
Commission § 1 (available at 
http://soswy.state.wy.us/Rules/RULES/5036.pdf).  

 
 
[¶39]   Section 27-14-616(b)(iv) states 
that the duties of the Medical Commission shall include:

 
 
(iv) 
To furnish three (3) members of the commission to serve as a medical hearing 
panel to hear cases referred for hearing.  
The division shall refer medically contested cases to the commission for 
hearing by a medical hearing panel.  
. . .  Following referral by 
the division, the hearing examiner or medical hearing panel shall have 
jurisdiction to hear and decide all issues related to the written notice of 
objection filed pursuant to W.S. 27-14-601(k).  Different medical hearing panels with 
different membership may be selected to hear different cases, but a panel may 
hear more than one (1) case.  
Individual medical hearing panels shall be selected by the executive 
secretary under the supervision and guidance of the chairman of the medical 
commission.  At least one (1) member 
of each panel shall be a physician.  
One (1) member shall be designated by the executive secretary to serve as 
chairman of the panel.  When hearing 
a medically contested case, the panel shall serve as the hearing examiner and 
shall have exclusive jurisdiction to make the final administrative determination 
of the validity and amount of compensation payable under this act.  

 
 
[¶40]   The Medical Commission is, 
therefore, permitted to assemble panels to hear individual medically contested 
worker's compensation cases.  In 
non-medically contested cases, a hearing examiner from the Office of 
Administrative Hearings, which was also created by statute, hears and decides 
the case.  Wyo. Stat. Ann. §§ 
9-2-2201, 27-14-602 (LexisNexis 2007).  
The Medical Commission panels have the same authority as hearing 
examiners to "hear and decide all issues" raised in the case.  Considering the plain language of the 
relevant statutes in the context of the entire scheme of worker's compensation 
contested cases, the Medical Commission panels clearly fall within the 
definition of an agency under § 16-4-402(a)(ii).  Although individual panels are selected 
for certain cases and then disbanded, when a panel is performing its statutory 
function, there is simply no question that it is an "authority, bureau, board, 
commission, committee, or subagency of the state."  Id.  
   

 
 
[¶41]   Moreover, the majority opinion is 
internally inconsistent.  The 
opinion concludes that the Public Meetings Act does not apply to the Medical 
Commission panel because it is not an agency and, yet, the opinion reviews the 
panel's decision by applying Wyo. Stat. Ann. § 16-3-114(c) (LexisNexis 2007) of 
the Wyoming Administrative Procedures Act.  
Section 16-3-114(a) articulates the method by which administrative agency 
decisions are judicially reviewed:

 
 
(a) 
Subject to the requirement that administrative remedies be exhausted and in the 
absence of any statutory or common-law provision precluding or limiting judicial 
review, any person aggrieved or 
adversely affected in fact by a final decision of an agency in a contested case, 
or by other agency action or inaction, or any person affected in fact by a rule 
adopted by an agency, is entitled to judicial review in the district court . 
. . . 

 
 
(emphasis 
added).  The judicial review 
provision of § 16-3-114(a) applies only to agency action.  If the Medical Commission panel's 
decision was not an agency action, as the majority opinion concludes, there is 
no basis for judicial review of that decision under the Administrative 
Procedures Act.  

 
 
[¶42]   A determination that the medical 
panel is an agency does not completely determine whether the Public Meetings Act 
applies to the deliberations of the panel.  
The Medical Commission claims that the panel's deliberations were exempt 
from the requirements of the Public Meetings Act in that they did not occur 
during a "meeting" as defined by § 16-4-402(a)(iii) because the panel does not 
make up a "quorum of the governing body of an agency."   Id.  

 
 
[¶43]   The Medical Commission consists of 
11 members and up to 11 "associate members."  Section 27-14-616(a), (b).  The function of associate members is 
limited to service on medical review panels.  Section 27-14-616(b).  Although the associate members do not 
participate in the other business of the Medical Commission, they do have 
complete authority to decide medically contested cases.  Section 27-14-616(b)(iv).  

 
 
[¶44]   A quorum is "the number of the 
members of an organized body of persons . . . that when duly assembled is 
legally competent to transact business in the absence of the other 
members."  Webster's Third New Int'l Dictionary 
1868 (1993).  Issuing decisions on 
medically contested cases is the statutorily enumerated "business" of the 
Medical Commission.  Section 
27-14-616(b)(iv).  A panel of three 
members of the Medical Commission is authorized by statute to transact that 
business, and is therefore legally competent to do so.  Id.  Consequently, a panel of three members 
of the Medical Commission is a quorum of the governing body of an agency for 
purposes of application of the Public Meetings Act.  

 
 
[¶45]   The Medical Commission also 
contends that it is entitled to meet to deliberate in private under the 
executive session exception in § 16-4-405(a)(ix):  

 
 
(a) 
A governing body of an agency may hold executive sessions not open to the 
public:

 
 
. 
. . .

 
 
(ix) 
To consider or receive any information classified as confidential by law[.]           

            

[¶46]   Initially, it must be noted that 
the record does not indicate the panel called an executive session.  Section 16-4-405(c) provides: "Unless a 
different procedure or vote is otherwise specified by law, an executive session 
may be held only pursuant to a motion that is duly seconded and carried by 
majority vote of the members of the governing body in attendance when the motion 
is made."  Section 16-4-405(b) 
requires that "[m]inutes shall be maintained of any executive session."  The record does not reflect that either 
of those requirements was fulfilled here.

 
 
[¶47]   Moreover, the matter at issue in 
this case did not qualify for consideration in executive session.  The Medical Commission directs us to 
Wyo. Stat. Ann. § 27-14-805 (LexisNexis 2007) for authority that the information 
discussed at Medical Commission panel hearings is confidential, and thus may be 
debated in an executive session.  
Section 27-14-805(a) states:

 
 
Except 
as otherwise provided by this act, information obtained from any employer or 
covered employee pursuant to reporting requirements under this act or 
investigations conducted under W.S. 27-14-803 shall not be disclosed in a manner 
which reveals the identity of the employer or employee except to the employer, 
the employee, legal counsel for an employer, legal counsel for an employee or in 
situations necessary for the division to enforce any of the provisions of this 
act.  

 
 
[¶48]   The statute prohibits the Workers' 
Compensation Division (Division) from disclosing identifiable information 
obtained "pursuant to reporting requirements under this act or investigations 
conducted under W.S. 27-14-803."  
Id.  The Division is permitted by statute to 
collect sensitive personal information in the interests of public safety, and 
the section prohibiting disclosure is an appropriate directive to protect that 
information.  Wyo. Stat. Ann. § 27-14-501 (LexisNexis 2007); 
Wyo. Stat. Ann. § 27-14-506 (LexisNexis 2007); 
Wyo. Stat. 
Ann. § 27-14-803 (LexisNexis 2007).  

 
 
[¶49]   Information gathered by the 
Division pursuant to reporting requirements is distinguishable from the 
information before the Medical Commission because the employer and employee are 
required to report it.  In contrast, 
information presented to the Medical Commission in a contested case hearing is 
presented pursuant to a claim made by the employee.  In choosing to avail himself of the 
system, the employee waives his right to maintain the privilege as to 
information relevant to the resolution of his case.  See Wardell v. McMillan, 844 P.2d 1052, 1066 
(Wyo. 1992) ("When a patient places his physical or mental condition into 
contest, the physician-patient privilege is waived to the extent that it is 
relevant to the controversy.") and Frias 
v. State, 722 P.2d 135, 140 (Wyo. 1986) ("Waiver also occurs when a party 
voluntarily inserts the issue of his physical condition into the 
litigation.").  Section 27-14-805 
prevents the disclosure of personal information gathered by the Division, not 
information presented by a claimant in a contested case proceeding.  Applying the Medical Commission's logic 
to the panels would allow closure, not just of the deliberations, but of the 
hearings and all other proceedings, as the information contained in those 
proceedings is the same as that discussed in deliberations.  That result is not consistent with the 
Medical Commission's practice and nothing in the statutes indicates it is what 
the legislature intended.  
Therefore, I would conclude the non-disclosure requirement of § 27-14-805 
does not allow deliberations by the Medical Commission's hearing panels to be 
held in executive session.4  

 
 
[¶50]   In summary, I would hold that the 
Medical Commission panels fit the statutory definition of "agency" under § 
16-4-402(a)(ii).  Deliberations of a 
panel constitute a "meeting" under § 16-4-402(a)(iii) where "action" is 
taken.  Section 16-4-402(a)(i).  Therefore, the deliberations of the 
Medical Commission's hearing panels must be held in conformity with the 
requirements of the Public Meetings Act.  
Action taken in contravention of the Public Meetings Act is void.  Section 16-4-403.  Because the hearing panel violated the 
law by deliberating in private, its order is void and we have nothing to 
review.  I would, therefore, remand 
this case to the Medical Commission for consideration using proper procedures 
under the Public Meetings Act.

 
 
FOOTNOTES

 
 

1Medical hearing panels operate under the 
Rules and Regulations promulgated by the Medical 
Commission.

 
 

2We found the 
theory presented to the medical hearing panel by Mr. Decker was "that his work 
materially aggravated his congenital condition."  Decker I, ¶ 40, 124 P.3d  at 
698.

 
 

3It is also 
inconsistent with the Medical Commission's determination that Dr. Johnson's 
December 5, 2001, unconditional work release indicates Mr. Decker's symptoms had 
resolved.

 
 

4The Medical 
Commission also cites to federal case law indicating that the deliberative 
process should be closed to the public to allow free and open debate among the 
panel members.  See, e.g., NLRB v. Sears, Roebuck & Co., 421 U.S. 132, 95 S. Ct. 1504, 44 L. Ed. 2d 29 (1975); Casad v. United States Dep't of Health and 
Human Serv's, 301 F.3d 1247 (10th Cir. 2002).  Those cases are not persuasive authority 
on the issue presented here because they concerned the federal Freedom of 
Information Act (FOIA), 5 U.S.C. § 552, not the Wyoming Public Meetings 
Act.  Moreover, the Public Meetings 
Act does not contain provisions comparable to those discussed in the cited 
cases.