Title: ORMSCO, INC. V. GARY BLACKBURN; DR. ERIN GREER, KENTUCKY ONE HEALTH-PCA, ET AL.

State: kentucky

Issuer: Kentucky Supreme Court

Document:

IMPORTANT NOTICE NOT TO BE PUBLISHED OPINION THIS OPINION IS DESIGNATED "NOT TO BE PUBLISHED." PURSUANT TO THE RULES OF CIVIL PROCEDURE PROMULGATED BY THE SUPREME COURT, CR 76.28(4){C), THIS OPINION IS NOT TO BE PUBLISHED AND SHALL NOT BE CITED OR USED AS BINDING PRECEDENT IN ANY OTHER CASE IN ANY COURT OF THIS STATE; HOWEVER, UNPUBLISHED KENTUCKY APPELLATE DECISIONS, RENDERED AFTER JANUARY 1, 2003, MAY BE CITED FOR CONSIDERATION BY THE COURT IF THERE IS NO PUBLISHED OPINION THAT WOULD ADEQUATELY ADDRESS THE ISSUE BEFORE THE COURT. OPINIONS CITED FOR CONSIDERATION BY THE COURT SHALL BE SET OUT AS AN UNPUBLISHED DECISION IN THE FILED DOCUMENT AND A COPY OF THE ENTIRE DECISION SHALL BE TENDERED ALONG WITH THE DOCUMENT TO THE COURT AND ALL PARTIES TO THE ACTION. RENDERED: AUGUST 29, 2019 NOT TO BE PUBLISHED 2018-SC-000543-WC ORMSCO, INC. APPELLANT ON APPEAL FROM COURT OF APPEALS V. CASE NO. 2017-CA-001227-WC WORKERS’COMPENSATION BOARD NO. 14-WC-91750 GARY BLACKBURN; DR. ERIN GREER, KENTUCKY ONE HEALTH-PCA; HON. JOHN B. COLEMAN, ADMINISTRATIVE LAW JUDGE; AND WORKERS’ COMPENSATION BOARD APPELLEES MEMORANDUM OPINION OF THE COURT REVERSING AND REMANDING Ormsc o , Inc ., appeal s fro m the Co urt o f Appeal s’ dec isio n upho l ding an Administrative Law Judge’s (ALJ) award o f 13% permanent partial disabil ity benefits to Gary Bl ac kburn bec ause o f a wo rk-rel ated injury. Ul timatel y, Ormsc o argues that the ALJ erred by making findings no t suppo rted by substantial evidenc e. Bec ause Kentuc ky l aw requires that a permanent impairment rating be determined pursuant to the fifth editio n o f the Americ an Medic al Asso c iatio n’s Guides to the Evaluation of Permanent Impairment (Guides), we agree with Ormsc o . Fo r the reaso ns stated bel o w, we reverse the Co urt o f Appeal s, reinstate the Bo ard’s o pinio n and remand to the ALJ fo r findings c o nsistent with this Opinio n. FACTS AND PROCEDURAL HISTORY Gary Bl ac kburn was hired by Ormsc o , Inc ., an equipment rental business, in 2009 to repair l awn mo wers, c hainsaws, smal l engines, weed eaters, and o ther equipment. His jo b required a c ertain degree o f physic al abil ity bec ause he was required to l o ad and unl o ad the equipment he repaired On Marc h 7, 2014, a trail er Bl ac kburn was using to retrieve a l awn mo wer bec ame stuc k. As he attempted to free it, he experienc ed a po p fo l l o wed by pain in his bac k. His bo ss met him at the sc ene o f the inc ident and thereafter Bl ac kburn so ught treatment at the emergenc y ro o m. When he arrived, he c o mpl ained o f pain in the middl e o f his bac k abo ve the bel t l ine, al o ng with tingl ing and numbness in his l eft l eg and to es. He was diagno sed with an L3 c o mpressio n frac ture, bac k pain and hypertensio n. The next day, Dr. Jean-Mauric e Page perfo rmed a kypho pl asty to repair the c o mpressio n frac ture at L3.1 Prio r to surgery, Dr. Page no ted that x-rays reveal ed an ac ute burst frac ture with a 50% l o ss o f height. In his o perative no te, Dr. Page indic ated the surgery was suc c essful and he was abl e to reduc e the c o mpressio n frac ture by al mo st 90%. Dr. Page rel eased Bl ac kburn to 1 1 A kypho pl asty is a pro c edure fo r stabil izing c o mpressio n frac tures that “uses spec ial bal l o o ns to c reate spac es within the vertebra that are then fil l ed with bo ne c ement.” It c an “c o rrec t spinal defo rmity and resto re l o st height.” Vertebroplasty, Mayo Clinic (Dec ember 28, 2017) https://www.mayo c l inic .o rg/tests- pro c edures/vertebro pl asty/abo ut/pa c -20385207. 2 return to regul ar wo rk o n June 24, 2014, with the restric tio n o f wearing a bac k brac e. Bl ac kburn testified that he wo re the brac e, and avo ided l ifting o ver 25 po unds, but he c o ntinued to experienc e bac k pain. He was abl e to wo rk witho ut restric tio n in the fal l o f 2014. Fro m the date o f his return thro ugh Marc h 18, 2016, Bl ac kburn rec eived a greater average weekl y wage than befo re his injury. Bl ac kburn visited Dr. Page several times after the surgery. On April 22, 2014, Dr. Page examined Bl ac kburn and stated that the x-rays o f the l umbar spine reveal ed a stabl e appearanc e o f the kypho pl asty. On May 20, 2014, Dr. Page again stated that mul tipl e views o f the l umbar spine reveal ed that as a resul t o f the L3 kypho pl asty “exc el l ent height was ac hieved.” Dr. Page’s impressio n in the May 20 repo rt was that the o utc o me fro m the kypho pl asty was go o d. These same no tes were rec o rded in the repo rt fro m Dr. Page’s June 24, 2014 examinatio n. On September 18, 2014, Dr. Page indic ated that Bl ac kburn had ful l mo bil ity o f the l umbar spine and that no rmal disc height was o bserved. Bl ac kburn subsequentl y c l aimed he exac erbated his c o nditio n o n June 12, 2015 when he was jo l ted whil e o perating a bo bc at at wo rk. Bl ac kburn initiated a wo rkers’ c o mpensatio n c l aim o n No vember 16, 2015. Initial l y, o nl y the Marc h 7, 2014 injury was inc l uded but Bl ac kburn l ater amended his c l aim to inc l ude the al l eged exac erbatio n o f the injury that o c c urred o n June 12, 2015. On Jul y 15, 2016, he rec eived a terminatio n l etter fro m Ormsc o whic h stated that the c o mpany c o ul d no l o nger ac c o mmo date his restric tio ns, c iting 3 to the ful l duty wo rk rel ease fro m Dr. Page and an independent medic al examinatio n by Dr. Timo thy Kriss. Dr. Arthur Hughes had previo usl y eval uated Bl ac kburn o n Dec ember 15, 2015, and assessed a 13% who l e perso n impairment fo r the burst frac ture at L3 with 50% l o ss o f height. Dr. Hughes no ted that Bl ac kburn c o mpl ained o f persistent l o w bac k and l eft l eg pain and so the physic ian wo ul d restric t him to a jo b that al l o wed him to stand o r sit as needed with o nl y l ight l ifting and no twisting o f the bac k. Dr. Hughes stated that Bl ac kburn was no t at maximum medic al impro vement (MMI) but c o ul d be c o nsidered as suc h if he had no additio nal treatment. Dr. Timo thy Kriss eval uated Bl ac kburn o n Dec ember 23, 2015. He to o k a histo ry o f the injury and no ted his o pinio n, fro m reviewing the medic al rec o rds, that the o riginal c o mpressio n frac ture o nl y resul ted in a 20% l o ss o f height. He o pined that the kypho pl asty was suc c essful , l eaving o nl y minimal residual c o mpressio n, and no ted that an MRI c o nduc ted in Oc to ber 2015 was no rmal .2 The Oc to ber 2015 MRI and repo rt referenc ed by Dr. Kriss, and o ther physic ians, no ted “no ac ute c o mpressio n frac tures o r signific ant degenerative c hanges,” al so stating that it was an “unremarkabl e” MRI. He bel ieved that Bl ac kburn was engaging in sympto m exaggeratio n, stating that Bl ac kburn’s behavio r seemed so extreme that it was diffic ul t to c o nvey in writing. Dr. Kriss 2 Dr. Kriss’s repo rt states that he perso nal l y reviewed bo th the Marc h 7, 2014 and Oc to ber 23, 2015 CT and MRI sc ans, whereas Dr. Hughes o nl y reviewed radio l o gy repo rts written by o ther physic ians who reviewed sc ans, no t the sc ans themsel ves. 4 pl ac ed Bl ac kburn in Diagno sis Rel ated Estimate (DRE) c ervic al c atego ry II,3 rating him with a 5% who l e perso n impairment and stating that he saw no need fo r permanent restric tio ns.4 Dr. Kriss o pined that Bl ac kburn reac hed MMI o n Oc to ber 2, 2014, when he was disc harged fro m al l o rtho pedic and spinal c are. He al so stated that this time frame was c o nsistent with Bl ac kburn’s histo ry and repo rts, highl ighting things suc h as his return to wo rk with minimal restric tio ns in June 2014, the ful l mo bil ity o f the l umbar spine no ted o n September 18, 2014, and that Bl ac kburn o nl y experienc ed bac k pain whil e l ifting as o f September 18, 2014. On January 7, 2016, Bl ac kburn saw Dr. Grego ry D’Angel o fo r c o ntinuing l eft l eg and hip pain. He no ted that al tho ugh Bl ac kburn had radic ul ar-type sympto ms, his MRIs did no t substantiate radic ul o pathy. He stated that Bl ac kburn needed to be eval uated fo r the SI (sac ro il iac ) jo int but did no t see anything in regard to his hip o ther than so me arthritis. 3 Fo r l umbar spine injuries, the Guides inc l ude five c atego ries o f c ervic al impairment based o n individual patient histo ry, c l inic al studies, and sympto ms. Guides at 384. 4 Dr. Kriss stated numero us reaso ns fo r pl ac ing Bl ac kburn in DRE c ervic al c atego ry II, inc l uding: (1) the c o mpressio n frac ture was l imited to the anterio r vertebral bo dy o nl y; (2) Dr. Page ac hieved c l o se to 100% reduc tio n o f the mil d frac ture with the kypho pl asty; (3) absenc e o f any c o mminutio n (spl intering/shattering) o f the frac ture o n the o riginal CT sc an; (4) absenc e o f any retro pul sio n (5) no rmal al ignment; (6) absenc e o f steno sis o r neuro l o gic al c o mpressio n (7) absenc e o f neuro l o gic al sympto ms; (8) no rmal neuro l o gic al exam at every medic al eval uatio n; (9) c o mpl ete reso l utio n o f pain do c umented by Dr. Page and Dr. Hashmi, who was o ne o f Bl ac kburn ’s do c to rs in the emergenc y ro o m and who al so c reated the disc harge summary o n Marc h 9, 2014, and (10) Bl ac kburn ’s c ho ic e to remo del his ho me in No vember 2014 in additio n to wo rking ful l -time, ful l duty. 5 Dr. Hughes was depo sed o n Marc h 2, 2016, and reveal ed that he based his impairment rating o n Dr. Page’s repo rt refl ec ting the c o mpressio n frac ture being at 50% prio r to surgery as sho wn in an x-ray. The atto rney questio ning Dr. Hughes no ted that the Guides al l o w c atego rizing an impairment in DRE c ervic al c atego ry III when a healed c o mpressio n frac ture has a remaining c o mpressio n that is 25-50%, and Dr. Hughes agreed and stated his o pinio n that it takes six weeks fo r a c o mpressio n frac ture to heal . (Emphasis added). Dr. Hughes did no t o rder any x-rays and did no t have any diagno stic fil ms fo r his review as part o f the examinatio n. He admitted that Dr. Page’s no te abo ut the 50% l o ss in height was the o nl y referenc e in the entire rec o rd avail abl e to him abo ut the extent o f the frac ture. Additio nal l y, he stated that an examiner wo ul d need an ac tual x-ray to measure the c urrent degree o f c o mpressio n after a frac ture heal s. Dr. Matthew Tutt examined Bl ac kburn o n May 19, 2016, and reviewed the Oc to ber 2015 MRI. Dr. Tutt stated that the MRI was underwhel ming, and that Bl ac kburn’s repo rted sympto ms were c o mpl etel y o ut o f pro po rtio n to what he o bserved in the MRI. After perfo rming a new MRI, Dr. Tutt examined Bl ac kburn again o n August 15, 2016, and repo rted a pro babl e c o mpressio n frac ture at L4, but that “vertebral bo dy heights are no rmal .” The MRI al so indic ated that the kypho pl asty at L3 had no c o mpl ic atio n and no instabil ity. Dr. Tutt further indic ated that whil e he was unsure whether the new L4 frac ture was rel ated to the previo us L3 kypho pl asty, he “preferfred] to think no t,” due to the pl ac ement o f the kypho pl asty c ement. 6 Bl ac kburn al so fil ed the medic al repo rt o f Dr. Steven Autry who examined him o n No vember 9, 2016. Dr. Autry to o k a histo ry o f Bl ac kburn’s injuries and subsequent treatment, and al so reviewed the diagno stic studies. Dr. Autry bel ieved Bl ac kburn al so had a l umbar frac ture at L4. He pl ac ed Bl ac kburn in DRE c ervic al c atego ry III fo r having frac tures at L3 and L4 with greater than 25% l o ss o f height. He assessed a 13% impairment fo r the c o mpressio n frac tures at L3 and L4, but no tabl y he did no t spec ify the perc entage attributabl e to eac h l evel . Additio nal l y, Dr. Autry assessed a 7% impairment fo r Bl ac kburn’s right ro tato r c uff, whic h he bel ieved was asso c iated with Bl ac kburn’s use o f c rutc hes whil e dragging his fo o t.5 The ALJ c o nduc ted a hearing o n Dec ember 7, 2016. After reviewing the evidenc e, o n February 1, 2017, the ALJ determined that Bl ac kburn retained a 13% who l e perso n impairment as a resul t o f the L3 c o mpressio n frac ture. The ALJ stated that the June 12, 2015 injury was no t a new injury but instead was an exac erbatio n o f Bl ac kburn’s c o nditio n. The ALJ al so appl ied the 2x mul tipl ier pursuant to Kentuc ky Revised Statute (KRS) 342.740(1)(c )(2) bec ause Bl ac kburn was terminated due to c o ntinuing diffic ul ties at wo rk whic h c o ul d no l o nger be ac c o mmo dated. The o rder al so states that Ormsc o is required to pay al l reaso nabl e and nec essary medic al expenses fo r the c ure and 5 We no te that Dr. Autry’s repo rt states that Bl ac kburn has a 13% who l e perso n impairment fo r “l umbar vertic al frac ture L3, L4 . . .” and a 7% who l e perso n impairment fo r right ro tato r c uff tendino sis and impingement. In the next sec tio n titl ed “c o mbinatio n o f val ues” Dr. Autry l ists 19%. It is unc l ear where the typo o c c urred, sinc e adding 13% and 7% equal s 20%, no t the 19% l isted as the c o mbinatio n o f val ues. 7 rel ief o f the L3 c o mpressio n frac ture, but no t fo r expenses asso c iated with Bl ac kburn’s l eft hip and ro tato r c uff. The ALJ no ted that the po int o f c o ntentio n between the parties was whether the frac ture resul ted in a 20% o r a 50% l o ss o f height. The ALJ fo und that Dr. Page “was by far in the best po sitio n to determine the l o ss o f height as he perfo rmed the surgic al repair” and that Dr. Page had mo re c redibil ity o n the issue. The ALJ rec o gnized that after the kypho pl asty and heal ing, Bl ac kburn’s 50% l o ss o f height was signific antl y reduc ed and he rel ied o n an exampl e c o ntained in the Guides. The exampl e invo l ved a burst frac ture with a 55% l o ss o f height that was treated with brac ing and heal ed to a 60% l o ss o f height. In the exampl e there is no mentio n o f surgic al treatment. The ALJ stated that this exampl e did no t indic ate whether the measurement was taken after treatment and assessed the 13% impairment in ac c o rdanc e with the o pinio ns o f Dr. Hughes and Dr. Autry. Ormsc o fil ed a petitio n fo r rec o nsideratio n stating that it was erro r fo r the ALJ to base the award o n the degree o f c o mpressio n frac ture fo und o n the date o f the injury, rather than when MMI was reac hed. Additio nal l y, Ormsc o no ted that the ALJ did no t no te whether the newfo und c o mpressio n frac ture at L4 as repo rted by Dr. Tutt was wo rk-rel ated. Upo n rec o nsideratio n, the ALJ stated that the Guides c l earl y reveal that the degree o f the c o mpressio n frac ture is the basis fo r the pl aintiff being pl ac ed into a DRE c ervic al c atego ry. Additio nal l y, two physic ians pl ac ed Bl ac kburn in DRE c ervic al c atego ry III and tho se o pinio ns were suppo rted by treating physic ian rec o rds. As to the L4 8 frac ture, the ALJ agreed with Ormsc o that there was a l ac k o f pro o f that the newl y-disc o vered frac ture was rel ated to the o riginal wo rk injury and rel ieved Ormsc o o f the respo nsibil ity o f paying the medic al expenses asso c iated with the L4 frac ture. Ormsc o appeal ed the ALJ’s dec isio n and o n June 30, 2017, the Wo rkers’ Co mpensatio n Bo ard (Bo ard) remanded the c l aim to the ALJ fo r additio nal findings o f fac t and entry o f an amended o pinio n. The Bo ard vac ated the ALJ’s award o f permanent partial disabil ity benefits bec ause the medic al eval uatio ns the ALJ rel ied o n did no t c o mpo rt with the Guides, whic h state that an individual with a spinal c o nditio n sho ul d be rated fo r impairment o nc e MMI has been reac hed. Sinc e the ALJ rel ied o n Dr. Hughes, who rated Bl ac kburn’s impairment based o n an x-ray taken befo re his surgery, and o n Dr. Autry, who eval uated Bl ac kburn after the L4 frac ture that was determined to be no n-wo rk- rel ated, no substantial evidenc e suppo rted the ALJ’s award. Whil e Bl ac kburn indisputabl y sustained a c o mpensabl e injury to his L3 vertebra, any award fo r permanent partial disabil ity benefits “must be based upo n Bl ac kburn’s c o nditio n when he reac hed MMI, and must no t inc l ude any assessment fo r the unrel ated L4 c o nditio n.” Bl ac kburn appeal ed the Bo ard’s dec isio n to the Co urt o f Appeal s. The Co urt o f Appeal s hel d that the Bo ard misc o nstrued c o ntro l l ing autho rity and fl agrantl y erred in eval uating the evidenc e. The Co urt o f Appeal s stated that the Bo ard c ritic ized the ALJ’s rel ianc e o n Dr. Hughes’s eval uatio n bec ause he assessed Bl ac kburn’s impairment prio r to the surgery, but Dr. Kriss empl o yed 9 the same metho ds. No ting that it is within the ALJ’s disc retio n to rel y o n o ne eval uatio n o ver ano ther, the Co urt o f Appeal s c o nc l uded that the Bo ard effec tivel y substituted its judgment fo r that o f the ALJ, whic h is impro per. Ormsc o appeal ed to this Co urt, arguing that, as a matter o f l aw, the ALJ fail ed to fo l l o w the Guides in assessing Bl ac kburn’s impairment. Mo re spec ific al l y, Ormsc o argues that the ALJ erred in rel ying o n impairment ratings that were assessed based o n signs and sympto ms as they existed prio r to surgery and thus prio r to MMI. Bec ause Kentuc ky mandates the use o f the Guides in assessing the impairment rating used in c al c ul ating permanent partial disabil ity benefits, we agree with Ormsc o . ANALYSIS The so l e issue is whether substantial evidenc e suppo rted the impairment rating assigned to Bl ac kburn fo r use in c al c ul ating the permanent partial disabil ity award. “The pro per interpretatio n o f the Guides and the pro per assessment o f impairment are medic al questio ns.” Lanter v. Ky. State Police, 171 S.W.3d 45, 52 (Ky. 2005). Ho wever, the ALJ has disc retio n to c ho o se the rating used as the basis fo r an award o f permanent partial disabil ity benefits. Pella Corp. v. Bernstein, 336 S.W.3d 451, 453 (Ky. 2011). KRS 342.730(l )(b) go verns the c al c ul atio n o f permanent partial disabil ity benefits whic h inc l udes “the permanent impairment rating c aused by the injury o r o c c upatio nal disease as determined by the ‘Guides to the Eval uatio n o f Permanent Impairment.’” KRS 342.0011(37) spec ifies that Kentuc ky uses the fifth editio n o f the Guides. Whil e the ALJ has disc retio n in determining whic h medic al evidenc e is mo st 10 persuasive, Kentucky River Enters, v. Elkins, 107 S.W.3d 206, 210 (Ky. 2003), the ALJ is c o nstrained by KRS 342.730(l )(b) whic h requires an impairment rating to be determined by the Guides. On appel l ate review, this Co urt must determine whether substantial evidenc e o f pro bative val ue suppo rts the ALJ’s findings. Whittaker v. Rowland, 998 S.W.2d 479, 481-82 (Ky. 1999). Substantial evidenc e is evidenc e o f “substanc e and rel evant c o nsequenc e” having fitness to induc e c o nvic tio n in the minds o f reaso nabl e peo pl e. Miller v. Tema Isenmann, Inc., 542 S.W.3d 265, 270 (Ky. 2018). In awarding benefits, the ALJ rel ied o n the medic al o pinio ns o f Dr. Hughes and Dr. Autry. Ormsc o argues that Dr. Autry’s assessment c anno t c o nstitute substantial medic al evidenc e bec ause Dr. Autiy assessed a c o mbined impairment fo r the injuries at L3 and L4. The ALJ determined upo n rec o nsideratio n that there was insuffic ient pro o f that the L4 frac ture was rel ated to the o riginal wo rk injury. Based o n Dr. Autiy’s eval uatio n and repo rt, it is unc l ear whic h part o f his 13% who l e perso n impairment rating is a resul t o f the L3 frac ture and whic h part resul ts fro m the newl y-disc o vered L4 frac ture. Bec ause Dr. Autry did no t appo rtio n the impairment between L3 and L4, his assessment c anno t c o nstitute substantial evidenc e. We agree that bec ause Dr. Autry’s impairment rating do es no t appo rtio n impairment between L3 and L4, and bec ause the ALJ o rdered o n rec o nsideratio n that Ormsc o is no t respo nsibl e fo r the medic al expenses asso c iated with the L4 injury, that Dr. Autry’s impairment rating c anno t suppo rt an award o f benefits fo r the L3 injury standing al o ne. 11 Ormsc o al so argues that Dr. Hughes’s o pinio n regarding impairment c anno t c o nstitute substantial evidenc e sinc e his assessment was based upo n an x-ray taken prio r to Bl ac kburn’s surgery, and he did no t review any testing subsequent to the surgery o r subsequent to Bl ac kburn reac hing MMI. We agree. In this c ase, the physic ians eval uated Bl ac kburn using the DRE metho d, whic h stands fo r diagno sis rel ated estimate, and is the princ ipal metho d used to eval uate individual s l ike Bl ac kburn who have a distinc t injury. Guides at 379. When determining the appro priate DRE c atego ry, the Guides state “[t]he impairment rating is based on the condition once MMI is reached, not on prior symptoms or signs.” Id. at 383 (emphasis in o riginal ). The Guides inc l ude a c hart o utl ining the spine eval uatio n pro c ess and the first step asks whether the individual is at MMI. Guides at 380. If yes, the eval uato r is instruc ted to pro c eed to the next step, whic h is determining whether the impairment is due to injuiy o r il l ness. If the individual has no t reac hed MMI, the c hart instruc ts the eval uato r to “[a]wait MMI.” Id. Further, the intro duc tio n to the sec tio n o n spinal injuries states that “an individual with a spinal c o nditio n is rated o nl y when the c o nditio n is stabl e (unl ikel y to c hange within the next year regardl ess o f treatment), i.e., when MMI has been reac hed.” Guides at 374. Additio nal sec tio ns o f the Guides further suppo rt the Bo ard’s o pinio n that the ALJ erred in rel ying o n Dr. Hughes and Dr. Autry. In Chapter 1, the Guides state “(a]n impairment is c o nsidered permanent when it has reac hed maximal medical improvement (MMI), meaning it is wel l stabil ized and 12 unl ikel y to c hange substantial l y in the next year with o r witho ut medic al treatment.” Guides at 2 (emphasis in o riginal ). MMI is defined as “[a] c o nditio n o r state that is wel l stabil ized and unl ikel y to c hange substantial l y in the next year, with o r witho ut medic al treatment. Over time, there may be so me c hange; ho wever, further rec o very o r deterio ratio n is no t antic ipated.” Guides at 601. Additio nal l y, as the Bo ard stated, “[i]t is apparent the impairment rating ado pted by the ALJ in this c ase is based upo n Bl ac kburn’s c o nditio n bo th prio r to reac hing MMI, and in fac t prio r to undergo ing kypho pl asty surgery . . . .” Dr. Hughes pl ac ed Bl ac kburn in DRE c ervic al c atego ry III due to the burst frac ture at L3 with a 50% l o ss o f height. He al so o pined that Bl ac kburn had no t yet reac hed MMI, unl ess no further treatment was appro ved. In his depo sitio n he stated that he rel ied o n Dr. Page’s c o nsul tatio n repo rt fro m Marc h 8, 2014, whic h was based o n an x-ray c o nduc ted befo re the surgery was perfo rmed. The c o nsul tatio n o c c urred o n Marc h 8, 2014, and happened befo re Bl ac kburn’s surgery, bec ause the repo rt go es o n to say that Dr. Page’s pl an is to perfo rm the kypho pl asty and that c o nsent wil l be o btained. During the depo sitio n Dr. Hughes admitted that the no te regarding 50% l o ss o f height is based o n o bservatio ns befo re Bl ac kburn’s surgery. The atto rney depo sing Dr. Hughes highl ighted that the Guides al l o w c atego rizatio n in DRE c ervic al c atego ry III when a heal ed c o mpressio n frac ture has a remaining c o mpressio n between 25 to 50% and Dr. Hughes affirmed this princ ipl e. Further, when asked general l y abo ut the time it takes fo r a 13 c o mpressio n frac ture to heal , Dr. Hughes stated that the frac ture wo ul d need to be eval uated six weeks po st-kypho pl asty. Dr. Hughes did no t o rder any x- rays and had no diagno stic fil ms avail abl e fo r his review — o nl y repo rts. He further expl ained that Dr. Page’s repo rt indic ating a 50% l o ss in height was the o nl y referenc e avail abl e to him in the entire rec o rd abo ut the extent o f the frac ture. In suppo rt o f the award, the ALJ stated that Dr. Page “was by far in the best po sitio n to determine the l o ss o f height as he perfo rmed the surgic al repair” and that in rec o gnizing the differing o pinio ns o n the issue, Dr. Page had mo re c redibil ity. Dr. Page’s rec o rds c o ntain several no tes that suppo rt the po sitio n that Bl ac kburn’s surgery was suc c essful and that the 50% l o ss o f height was surgic al l y reduc ed, inc l uding: (1) the po st-o perative diagno sis repo rt stating that the “frac ture is reduc ed al mo st to 90%”; (2) the Marc h 24, 2014 repo rt stating that two views o f the l umbar spine were perfo rmed and reviewed and that Bl ac kburn’s status po st-o peratio n was exc el l ent; (3) the April 22, May 20 and June 24, 2014 examinatio n repo rts stating that x-rays reveal ed the kypho pl asty was stabl e based o n mul tipl e views o f the l umbar spine, that “exc el l ent height was ac hieved” surgic al l y, and “[i]mpressio n: kypho pl asty go o d o utc o me”; and (4) the September 18, 2014 examinatio n no tes stating Bl ac kburn had ful l mo bil ity o f the l umbar spine, no rmal disc height was o bserved, and the kypho pl asty rendered a go o d o utc o me. Given the no ted suc c ess o f the surgery and the po sitive indic atio ns po st-o peratio n, it is no t reaso nabl e to bel ieve that if Bl ac kburn suffered a 50% l o ss in height after the 14 injury and prio r to surgery, that he retained the same l o ss in height after a suc c essful surgery. “An ALJ c anno t c ho o se to give c redenc e to an o pinio n o f a physic ian assigning an impairment rating that is no t based upo n the AMA Guides. Any assessment that disregards the express terms o f the AMA Guides c anno t c o nstitute substantial evidenc e to suppo rt an award o f wo rkers' c o mpensatio n benefits.” Watkins v. Kobe Aluminum USA, Inc., 2013-SC-000334-WC, 2014 WL 4160212, at *3 (Ky. Aug. 21, 2014) (quo ting Jones v. Brasch-Barry General Contractors, 189 S.W.3d 149, 153-54 (Ky. App. 2006)). Whil e the interpretatio n o f the Guides is indisputabl y to be l eft to medic al pro fessio nal s, it do es no t take a medic al pro fessio nal to no te that the Guides require impairment ratings to be assessed after MMI is reac hed. The ALJ did no t make spec ific findings regarding when Bl ac kburn reac hed MMI, but the ALJ awarded tempo rary to tal disabil ity benefits thro ugh June 24, 2014, when Dr. Page rel eased him to return to wo rk whil e wearing a bac k brac e. As to the c l ear indic atio n that Bl ac kburn’s l o ss o f height was remedied by surgery, the ALJ’s o pinio n rec o gnizes that “it appears that after heal ing, the 50% l o ss o f height was signific antl y reduc ed.” Ho wever, the ALJ uses an exampl e in the Guides to ratio nal ize why he stil l bel ieved that pl ac ement in DRE c ervic al c atego ry III fo r a 25-50% c o mpressio n frac ture o f a vertebral bo dy is appro priate. The ALJ no tes that Exampl e 15-5 set fo rth in the Guides do es no t indic ate o r l eaves the impressio n that the height l o ss measurement was taken after treatment. Guides at 387. Instead, the individual in the exampl e 15 was assessed into DRE c ervic al c atego ry IV fo r having a burst frac ture with greater than 50% l o ss o f height with neuro l o gic al findings. Id. The exampl e invo l ves a 54-year o l d wo man who fel l fro m a l adder and sustained a burst frac ture with a 55% l o ss o f height. Id. She was treated with brac ing and the frac ture heal ed. Id. The c l inic al studies indic ated that the frac ture “healed with a 60% loss of height,” so she was pl ac ed in DRE IV fo r having a burst frac ture greater than 50%. Id. (emphasis added). The exampl e do es no t indic ate that the individual was treated with surgery, and instead suggests that the frac ture wo rsened. The ALJ stated that the exampl e “do es no t indic ate o r l eaves the impressio n the measurement was taken after treatment.” But the exampl e states the frac ture “heal ed” with a 60% l o ss, suggesting that the degree o f the frac ture was assessed after heal ing, whic h Dr. Hughes stated wo ul d take appro ximatel y six weeks. Therefo re, it is no t reaso nabl e to base an impairment rating o n the assessment o f a frac ture c o nduc ted befo re surgery and befo re it has had time to heal . The ALJ’s rel ianc e o n this exampl e is c o nfusing, at best, and do es no t hel p expl ain the rel ianc e o n the frac ture assessments c o nduc ted prio r to Bl ac kburn’s surgery. Further, the interpretatio n o f the Guides is a medic al questio n and no medic al repo rts in the rec o rd c o ntain referenc e to this exampl e used by the ALJ. On this appeal , Bl ac kburn argues that the Bo ard misundersto o d Dr. Kriss’s eval uatio n and repo rt. Dr. Kriss stated that he perso nal l y reviewed the Marc h 2014 pre-surgery CT sc an o f the l umbar spine and bel ieved that there was o nl y a 20% l o ss o f height. Additio nal l y, he reviewed the Oc to ber 2015 MRI 16 and o pined that the L3 vertebral bo dy retained a 10% o r l ess c o mpressio n, whic h was “substantial l y reduc ed to wards no rmal ” c o mpared to the Marc h 2014 CT sc an. He al so no ted that the c ement inserted during the kypho pl asty was perfec tl y po sitio ned to reduc e and stabil ize the previo us L3 c o mpressio n frac ture. Bl ac kburn spec ific al l y c ritic izes Dr. Kriss’s referenc e to a 20% frac ture and states that the Bo ard c l earl y misundersto o d this evidenc e. Ho wever, this referenc e seems to be based o n Dr. Kriss’s o pinio n, that after reviewing the pre surgery Marc h 2014 diagno stic s, Bl ac kburn’s frac ture resul ted in o nl y a 20% l o ss o f height, no t a 50% l o ss as indic ated by Dr. Page. The referenc es o n page 17 o f Dr. Kriss’s repo rt, as highl ighted by Bl ac kburn, seem to be referring to the o riginal injury whic h Dr. Kriss used to suppo rt his o pinio n that Bl ac kburn has an exc el l ent l o ng-term pro gno sis. Upo n review, the Bo ard o ffered l ittl e disc ussio n o f Dr. Kriss’s medic al o pinio n and this disc ussio n seemed to ac c uratel y summarize Dr. Kriss’s repo rt in the rec o rd. Bl ac kburn al so argues that bo th Dr. Kriss and Dr. Hughes assessed Bl ac kburn’s impairment l o ng after he reac hed MMI in Oc to ber 2014. Ho wever, this Co urt bel ieves the Guides do no t mean that the eval uatio n itsel f must be c o nduc ted after MMI is reac hed, but rather the impairment rating must be based o n the empl o yee’s c o nditio n o nc e MMI is reac hed. Al tho ugh it is undisputed that Dr. Hughes assessed Bl ac kburn’s impairment at a time after Bl ac kburn reac hed MMI, Dr. Hughes rel ied o n medic al repo rts c reated befo re surgery and befo re Bl ac kburn heal ed, therefo re befo re he reac hed MMI. 17 CONCLUSION Bec ause the repo rt and subsequent testimo ny o f Dr. Hughes do es no t c o nstitute substantial evidenc e as required when determining an impairment rating, and bec ause Dr. Autry’s o pinio n did no t appo rtio n the impairment fo r the L3 and L4 injuries, the ALJ’s o pinio n c anno t stand. Whil e no o ne disputes that Bl ac kburn sustained a c o mpensabl e injury to his L3 vertebra, any suc h award fo r impairment must be based o n the Guides and c anno t inc l ude assessment fo r an unrel ated c o nditio n. Therefo re, we reverse the Co urt o f Appeal s’ o pinio n, reinstate the Bo ard’s o pinio n and c o nsequentl y remand to the ALJ fo r findings c o nsistent with this Opinio n. Minto n, C.J.; Buc kingham, Hughes, Kel l er, VanMeter, and Wright, JJ., sitting. Al l c o nc ur. Lambert, J., no t sitting. COUNSEL FOR APPELLANT: Sc o tt Mitc hel l Burns Bro wn FOWLER BELL PLLC COUNSEL FOR APPELLEE, GARY BLACKBURN:: Mc Kinnl ey Mo rgan MORGAN COLLINS YEAST & SALYER 18