Title: In the matter of the Workers' Compensation Claim of: MILTON RODGERS v. STATE OF WYOMING, ex rel., WYOMING WORKERS' SAFETY AND COMPENSATION DIVISON

State: wyoming

Issuer: Wyoming Supreme Court

Document:

In the matter of the Workers' Compensation Claim of: MILTON RODGERS v. STATE OF WYOMING, ex rel., WYOMING WORKERS' SAFETY AND COMPENSATION DIVISON2006 WY 65135 P.3d 568Case Number: No. O5-144Decided: 05/31/2006
APRIL 
TERM, A.D. 2006

 
 

                                                                                                            

IN THE 
MATTER OF THE WORKER'S                             

COMPENSATION 
CLAIM OF:                                            

                                                                                                

MILTON 
RODGERS,

Appellant 
(Employee/Claimant),

                                                                                                

v.

                                                                                                                        

STATE OF 
WYOMING, ex rel., WYOMING WORKERS' 

SAFETY 
AND COMPENSATION DIVISION,

Appellee 
(Objector/Defendant).

 
 
Appeal 
from the DistrictCourtofLaramieCounty

 
 

Representing 
Appellant:

Kirk A. 
Morgan of Gage & Moxley, 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.  
Argument by Ms. Radosevich.

 
 
Before 
HILL, C.J., and GOLDEN, KITE, VOIGT, BURKE, JJ.

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Milton Rodgers 
suffered a work related back injury in 1983.  Since then, Rodgers has undergone 
twenty-one neck and back surgeries and has suffered chronic pain, which his 
physicians have treated with numerous narcotic pain medications.   In 1997, Rodgers began 
experiencing gastrointestinal problems caused by the narcotic pain 
medications.  The Wyoming Workers' 
Compensation Division (Division) paid Rodgers' claims relating to his 
gastrointestinal problems until 2002.  
The Division thereafter denied Rodgers' claims on the ground that the 
gastrointestinal problems for which Rodgers was treated after 2002 were no 
longer related to his pain medications.  
After a contested case hearing, the Medical Commission Hearing Panel 
upheld the denial of Rodgers' claim.  
Rodgers appealed to the district court, which affirmed the Medical 
Commission's decision.  Rodgers now 
appeals to this Court.  

 
 
[¶2]      This Court finds 
that the Medical Commission's order denying benefits violates the Wyoming 
Administrative Procedures Act ("Wyoming APA") by failing to set forth basic 
findings of fact to support its ultimate findings and by improperly taking 
judicial notice of certain facts.  
Where an agency order is facially insufficient to permit review, it is 
this Court's preference to remand for entry of a new order correcting the 
deficiencies.  In this case, though, 
we also find that the order denying benefits contains inaccurate findings and 
that it is on those inaccuracies that the Medical Commission based its decision 
to uphold the denial of benefits.  
Under these narrow circumstances, where we are correcting an inaccuracy 
in the findings of fact without reweighing the evidence, this Court will reverse 
the district court's decision and remand with directions to vacate the order 
denying benefits.  Further, the 
district court is to remand the case to the Medical Commission for entry of an 
order awarding benefits for the diagnosis and treatment of Rodgers' 
gastrointestinal problems and esophageal stricture.

 
 
 
 
ISSUES

 
 
[¶3]      Rodgers presents 
the following issues for our review:

 
 
I.  Whether the Medical Commission's 
holding, regarding Mr. Rodgers's gastrointestinal disorders, [is] supported by 
substantial evidence when the record is viewed in its 
entirety.

 
 
II.  Whether the Medical Commission erred, as 
a matter of law, by providing findings of fact and conclusions of law that are 
inadequate and contrary to W.S. § 16-3-110 regarding Mr. Rodgers's 
gastrointestinal problems.

 
 
III.  Whether the Medical Commission's 
holding, regarding Mr. Rodgers's esophageal stricture, is supported by 
substantial evidence when the record is viewed in its 
entirety.

 
 
IV.  Whether the Medical Commission's 
decision was arbitrary and capricious because it illegally took judicial notice 
of a contested fact and failed to follow the procedures required by W.S. § 
16-3-108(d) when taking judicial notice.

 
 
The 
Division reframes the issues as:

 
 
I.  Whether substantial evidence supports 
the Medical Commission's decision denying workers' compensation benefits to 
Appellant?

 
 
II.  Whether the Medical Commission properly 
evaluated conflicting medical evidence and set out findings of fact which 
indicated which evidence the Medical Commission considered 
probative?

 
 
 
 
FACTS

 
 
[¶4]      On December 27, 
1983, Rodgers suffered a work-related back injury, which was diagnosed as an 
"acute traumatic lumbo-sacral sprain-strain complex."  Since his injury, Rodgers has undergone 
twenty-one failed back and neck surgeries and suffers from chronic back 
pain.  Rodgers' physicians have 
treated his chronic pain with numerous narcotic and non-narcotic pain 
medications.  

 
 
[¶5]      In March 1997, 
Rodgers began to experience abdominal pain for which he was seen by his primary 
care physician, Dr. Marion N. Smith.  
Dr. Smith attributed Rodgers' abdominal pain to his pain medication and 
referred him to Dr. Thomas G. Tietjen, a gastroenterologist.  Dr. Tietjen ordered an 
esophagogastroduodenoscopy (EGD), which was performed on April 3, 1997.  The EGD showed a "[d]uodenal ulcer with 
gastric outlet obstruction.  Diffuse 
gastritis with hemorrhage.  Severe 
duodenitis with erosions."  Dr. 
Tietjen prescribed Prilosec for Rodgers and directed him to return for a 
follow-up visit in four weeks.  

 
 
[¶6]      Four weeks later, 
on April 30, 1997, a second EGD was performed on Rodgers.  The second EGD showed (1) a "duodenal 
ulcer with less obstruction than on last EGD four weeks ago;" (2) "[m]oderately 
severe erosive gastritis;" and (3) "[n]ormal esophagus."  Dr. Tietjen took biopsies on this same 
date to rule out Helicobacter pylori ("H. pylori") bacteria and to confirm that 
Rodgers' condition was benign.  The 
biopsy results showed normal tissue and no identifiable H. pylori bacteria.  

 
 
[¶7]      Rodgers saw Dr. 
Tietjen for abdominal pain on three subsequent occasions, with the last recorded 
visit on April 24, 2000.  Findings 
during those visits included internal hemorrhoids, diverticulosis, ileus and/or 
nonmechanical gastric outlet obstruction resulting from narcotic medications, a 
normal esophagus, and mild erosive gastritis and a single acute ulcer in the 
postbulbar region of the duodenum caused by aspirin in the Fiorinal Rodgers was 
taking for pain.  

 
 
[¶8]      On May 17, 2001, 
Dr. Smith ordered an upper GI series and pharyngogram.  The tests showed no evidence of any 
stricture, mass or ulceration in the esophagus and no anatomic abnormalities of 
the pharynx or esophagus.  Dr. Smith 
referred Rodgers to the Center for Gastroenterology at PoudreValleyHospital in Fort Collins, Colorado, where Dr. Hugh P. McElwee on July 9, 
2001, performed an endoscopy, and on July 24, 2001, performed an esophageal 
motility test.  Following these 
procedures, Dr. McElwee noted:

 
 

Milton has 
what sounds like a proximal dysphagia.  
We did further evaluation with upper endoscopy on July 9, 2001 that 
showed a Schatzki's ring and some gastritis.  We did esophageal dilation and biopsy 
for H-pylori and the latter was negative.  
He got little or no benefit from the dilation and still has difficulty 
swallowing pills and other foods.  
He locates all of his distress in the upper esophagus.  Esophageal motility was done . . . and 
this was a normal study without obvious motility explanation for his 
dysphagia.  

 
 
[¶9]      Rodgers began 
seeing Dr. Charles Kuckel, a gastroenterologist, in October 2002.  On October 16, 2002, following two 
exams, an endoscopy and a biopsy, Dr. Kuckel diagnosed Rodgers with "dysphagia 
secondary to esophageal stricture/ulcer with gastritis secondary to H. pylori as 
well as duodenitis and duodenal ulcer."  
Dr. Kuckel prescribed antibiotics to treat the H. pylori infection and 
directed Rodgers to see him again in one month, noting that "it is most likely 
at that juncture we will have to have a repeat EGD in order to dilate that 
stricture."  

 
 
[¶10]   Rodgers saw Dr. Kuckel again on 
December 20, 2002, at which time Dr. Kuckel repeated his diagnosis of "dysphagia 
secondary to esophageal stricture as well as gastritis and duodenitis."  He added that Rodgers "also has symptoms 
of gastroparesis which are most likely secondary to his pain medications."  Dr. Kuckel thereafter performed an EGD 
on Rodgers on January 15, 2003, which "revealed the previously observed 
stricture with irregular and thickened mucosa was still present in the distal 
esophagus along with erosive esophagitis," erosive gastritis, and a hiatal 
hernia.  Dr. Kuckel performed an 
esophageal dilatation and ordered a repeat endoscopy and dilatation within the 
next month.  

 
 
[¶11]   On February 14, 2003, Rodgers 
underwent the repeat EGD and dilatation.  
On February 27, 2003, Dr. Kuckel followed up with Rodgers and 
noted:

 
 
Mr. 
Milton Rodgers is a 63-year-old Caucasian male with multiple medical problems 
who has dysphagia secondary to an esophageal stricture secondary to reflux and 
gastroparesis secondary to his chronic use of pain medication who is now 
improved with dilatation, EGD, and high-dose antacid-secretory medication.  

 
 
Dr. 
Kuckel also noted that Rodgers would likely require another esophageal 
dilatation within the next two months.  

 
 
[¶12]   On February 27, 2003, Rodgers also 
saw Dr. Peter G. Perakos, at the Division's direction, for an independent 
medical examination (IME).  Dr. 
Perakos opined as follows:

 
 
            
There is not an issue of causation with respect to the injury causing Mr. 
Rodgers' back pain.  I presume the 
issue may well be if the medications that he has been taking have caused his 
esophageal stricture.  This is a 
very difficult issue in that apparently the Division has already felt that there 
is a causal relationship.  As we do 
not have most of Dr. Tietjen's records I cannot be convinced that there is a 
causal relationship between his medications and causing his esophageal 
strictures or dysmotility of his esophagus, particularly in the setting of a 
normal esophageal motility study by Dr. McElwee within the past two years.  Based upon the information we have to a 
reasonable degree of medical probability there is not a probable causal 
relationship between the current complaint and the medications used and whatever 
is being referred to as a spinal stroke.  
We would like to have much more information with respect to the "spinal 
stroke" as we have difficulty with the anatomic understanding of what symptoms 
may result from the "spinal stroke."  
It is not clear what the event was that he had with the loss of feeling 
and the six months of post surgical rehab, whether or not there was identifiable 
neurologic loss.  

 
 
* * * * 

I next 
have a difficulty making a direct association with other medications possibly 
causing his stricture.  As I do not 
have good copies of the photos taken by Dr. Kuckel and I do not have the primary 
documents from Dr. McElwee, and I have virtually no documents from Dr. Tietjen, 
it is hard to put this together.  I 
suspect, however, that it would be a big leap to tie medications with the 
stricture.  

 
 
* * * * 

 
 
If Mr. 
Rodgers does have significant gastroesophageal reflux disease then that can 
contribute to worsening of the esophageal stricture.  

 
 
[¶13]   Rodgers saw Dr. Kuckel again on 
April 4, 2003, for a follow-up visit.  
Dr. Kuckel again repeated his diagnosis of Rodgers as suffering from "an 
esophageal stricture secondary to reflux and gastroparesis secondary to his 
chronic use of pain medication."  He 
also noted that Rodgers "is now improved status post EGD and dilatation and 
high-dose antacid secretory medication."  
Dr. Kuckel ordered a continuation of the medications as prescribed for 
the following six months with follow-up as needed if Rodgers' dysphagia symptoms 
increase.  

 
 
[¶14]   On May 16, 2003, the Division 
issued a Final Determination denying benefits for Rodgers' gastrointestinal 
disorders, stating, "Based on the results of the Independent Medical Examination 
performed by Dr. Peter G. Perakos on February 27, 2003, the treatments for 
gastrointestinal disorders are not related to the December 27, 1983 work injury 
to the back."  Rodgers' objected to 
the Final Determination and requested a hearing.  A contested case hearing was held before 
the Medical Commission, and on August 16, 2004, the Medical Commission issued a 
decision upholding the denial of benefits.  

 
 
[¶15]   In reaching its decision, the 
Medical Commission included the following in its findings of 
fact:

 
 
            
We find Dr. Kuckel's opinion to be persuasive in this matter regarding 
Mr. Rodgers' care and treatment through August of 2002.  Dr. Kuckel is Board Certified in 
internal medicine and board-eligible in gastroenterology and was unequivocal in 
his opinion that the variety of medications being taken by Mr. Rodgers were the 
primary causative agent of his gastrointestinal problems.  Dr. Kuckel described Mr. Rodgers as 
taking "prodigious doses of narcotics." (Kuckel Deposition, p. 
30)

            
In response to his attorney's question, ". . . real quickly Doctor, his 
condition, his dysphagia, gastritis, duodenitis, and gastroparesis, do you 
believe that all of these are caused by or are secondary to his use of pain 
medication?"  Dr. Kuckel replied, "I 
believe that this is the case, yes."  
(Kuckel deposition, page 22)  
We agree with Dr. Kuckel's conclusions regarding those issues, but note 
that he was NOT questioned on the esophagitis, hiatal hernia, esophageal 
stricture, esophageal dilation and Schatzi's ring are not mentioned in his 
opinion, and we find that those conditions are not related to his narcotic pain 
medication usage.  It is noteworthy 
that Mr. Rodger's quit using Fiorinal on 3/12/02 and did not have significant 
esophageal disease until 7 months later, leading us to find that the medications 
played no role in the esophageal stricture.  

 
 
The 
Medical Commission concluded its decision as follows:

 
 
We 
conclude that the care and treatment provided to Mr. Rodgers regarding his 
gastrointestinal system through August of 2002 is reasonable and necessary 
medical care and is directly and causally related to the treatment of his work 
injury and the medications for that injury and is therefore compensable.  Care and treatment for the esophageal 
stricture, which surfaced in October of 2002, has not been proven to be caused 
by, or related to his work injury of December 27, 19[8]3 and is therefore not 
compensable.  

 
 
 
 
STANDARD 
OF REVIEW

 
 
[¶16]   A worker's compensation claimant 
has the burden of proving every essential element of his claim by a 
preponderance of the evidence.  Decker v. State ex rel. Wyoming Medical 
Comm'n, 2005 WY 160, ¶ 21, 124 P.3d 686, 693 (Wyo. 2005); Cramer v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2005 WY 124, ¶ 8, 120 P.3d 668, 670 (Wyo. 
2005).  "Under the statutory 
definition of injury, he must prove that his injury arose out of and in the 
course of his employment.  Whether 
an employee's injury occurred in the course of his employment is a question of 
fact."  Id.

 
 
[¶17]   When reviewing an administrative 
agency order, we review the case as if it came directly from the administrative 
agency, affording no deference to the district court's  decision.  Hicks v. State ex rel. Wyoming Workers' 
Safety and Comp. Div., 2005 WY 11, ¶ 16, 105 P.3d 462, 469 (Wyo. 2005).  The scope of our review is governed by 
Wyo. Stat. Ann. § 16-3-114(c) (LexisNexis 2005), which 
provides:

 
 
(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:

            
(i) Compel agency action unlawfully withheld or unreasonably delayed; and 

            
(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;

(B) 
Contrary to constitutional right, power, privilege or 
immunity;

(C) In 
excess of statutory jurisdiction, authority or limitations or lacking statutory 
right;

(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.

 
 
[¶18]   In appeals where both parties to a 
contested case submit evidence, appellate review of the evidence is limited to 
application of the substantial evidence test.  Berg v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2005 WY 23, ¶ 7, 106 P.3d 867, 870 (Wyo. 2005); Newman v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2002 WY 91, ¶ 22, 49 P.3d 163, 171 (Wyo. 
2002).  We review the entire record 
and apply the substantial evidence test as follows:

 
 
In 
reviewing findings of fact, we examine the entire record to determine whether 
there is substantial evidence to support an agency's findings.  If the agency's decision is supported by 
substantial evidence, we cannot properly substitute our judgment for that of the 
agency and must uphold the findings on appeal.  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.

 
 

Cramer, ¶ 10, 
120 P.3d  at 671.

 
 
[¶19]   Even if an agency record contains 
sufficient evidence to support the administrative decision under the substantial 
evidence test, this Court applies the arbitrary-and-capricious standard as a 
"safety net" to catch other agency action that may have violated the Wyoming 
Administrative Procedures Act.  Decker, ¶ 24, 124 P.3d  at 694; Loomer v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2004 WY 47, ¶ 15, 88 P.3d 1036, 1041 (Wyo. 
2004).  "Under the umbrella of 
arbitrary and capricious actions would fall potential mistakes such as 
inconsistent or incomplete findings of fact or any violation of due 
process."  Decker, ¶ 24, 124 P.3d  at 694 (quoting 
Padilla v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2004 WY 10, ¶ 6, 84 P.3d 960, 962 (Wyo. 
2004)).  

 
 
 
 
DISCUSSION

 
 
[¶20]   Rodgers argues the Medical 
Commission's findings of fact are unsupported by substantial evidence, that the 
findings are inadequate as a matter of law, and that the Medical Commission 
erred in taking judicial notice of a contested fact.  We agree that the Medical Commission's 
findings of fact do not meet the requirements of the Wyoming APA and that the 
Medical Commission improperly took judicial notice of a contested fact.  We further find that the Medical 
Commission's decision was arbitrary and capricious because it was based on 
inaccurate findings of fact and contrary to the overwhelming weight of the 
evidence.  Because of our resolution 
of these questions, we do not address Rodgers' substantial evidence 
arguments.  We will address first 
the deficiencies in the Medical Commission's findings of fact and then turn to 
our conclusion that the Medical Commission's decision was arbitrary and 
capricious.  

 
 
 
 

Findings 
of Fact

 
 
[¶21]   We recently addressed the 
fact-finding role of the Medical Commission in another worker's compensation 
case before this Court.  See Decker, ¶ 26, 124 P.3d  at 
694-95.  We explained: 

 
 
            
The Medical Commission was created in 1993 to serve a number of 
functions, including to provide three-member panels to hear medically contested 
workers' compensation claims.  
Wyo. 
Stat. Ann. § 27-14-616(b)(iv) (LexisNexis 2005).  When hearing a medically contested case, 
the panel serves as the hearing examiner with jurisdiction to make the final 
determination concerning the contested claim.  Id.  Hearings before Medical Commission 
panels are to be conducted in accordance with the Wyoming Administrative 
Procedure Act. See Himes v. Petro 
Engineering & Construction, 2003 WY 5, ¶ 19, 61 P.3d 393, 399 (Wyo. 
2003).  The Wyoming Administrative 
Procedure Act requires that "[f]indings of fact shall be based exclusively on 
the evidence and matters officially noticed."  Wyo. Stat. Ann. § 16-3-107(r) 
(LexisNexis 2005).  It also requires 
that an agency's final decision "include findings of fact and conclusions of law 
separately stated."  Wyo. Stat. Ann. § 
16-3-110 (LexisNexis 2005).

 
 

Decker, ¶ 26, 
124 P.3d  at 694-95.  Medical 
Commission members bring valuable experience and expertise to their review of 
Division decisions, but that review must be performed in accordance with the 
requirements of the Wyoming APA.  
Id. at ¶ 33, 124 P.3d  at 696-97.

 
 
[¶22]   We find the Medical Commission's 
decision in this case runs afoul of the Wyoming APA because it failed to weigh 
all of the material evidence offered by the parties, it made ultimate findings 
of fact unsupported by any basic findings, and it improperly took judicial 
notice of a contested fact.

 
 
 
 

Failure 
to Weigh Material Evidence

 
 
[¶23]   This Court has on numerous 
occasions over a span of years stressed the importance of an agency fact-finder 
giving careful consideration to all material evidence presented by the 
parties.

 
 
All of 
the material evidence offered by the parties must be carefully weighed by the 
agency as the trier of the facts;  
conflicts in the evidence must be resolved, and the underlying or basic 
facts which prompt the ultimate conclusion on issues of fact drawn by the agency 
in sustaining the prima facie case made, or in rejecting it for the reason it 
has been satisfactorily met or rebutted by countervailing evidence, must be 
sufficiently set forth in the decision rendered.

 
 

Decker, ¶ 27, 
124 P.3d  at 695 (quoting Bush v. State ex 
rel. Wyoming Workers' Safety & Comp. Div., 2005 WY 120, ¶ 9, 120 P.3d 176, 180 (Wyo. 2005) (quoting Pan Am. 
Petroleum Corp. v. Wyoming Oil & Gas Conservation Comm'n, 446 P.2d 550, 
557 (Wyo. 1968)); see also Olivas v. State ex rel. Wyoming Workers' 
Safety & Comp. Div.,  2006 
WY 29, ¶ 16, 130 P.3d 476, 485 (Wyo. 2006) ("[O]ur ability to review the hearing 
examiner's decision is further compromised by the hearing examiner's failure to 
make findings of fact and conclusions regarding all of the material evidence 
offered by [Claimant]."). 

 
 
[¶24]   This Court has been equally clear 
in its requirements for the consideration to be given medical opinion 
testimony.

 
 
When 
presented with medical opinion testimony, the hearing examiner, as the trier of 
fact, is responsible for determining relevancy, assigning probative values, and 
ascribing the relevant weight to be given to the testimony. . . .  In weighing the medical opinion 
testimony, the fact finder considers:  
(1) the opinion; (2) the reasons, if any, given for it; (3) the strength 
of it; and (4) the qualifications and credibility of the witness or witnesses 
expressing it.

 
 

Decker, ¶ 33, 
124 P.3d  at 697 (quoting Baxter v. 
Sinclair Oil Corp., 2004 WY 138, ¶ 9, 100 P.3d 427, 431 (Wyo. 2004) (quoting 
Bando v. Clure Bros. Furniture, 980 P.2d 323, 329 (Wyo. 1999))).

 
 
[¶25]   In this case, the Medical 
Commission's order contains no indication that it considered and weighed all 
material evidence offered by the parties.  
Our review of the record revealed numerous records and opinions material 
to the issues before the Medical Commission that were not discussed in the 
Medical Commission's order.  For 
example, the order does not reference in any manner the opinions offered by 
Rodgers' pain management specialist, Dr. John C. Oakley.  Dr. Oakley testified as 
follows:

 
 
            
Q.        Could 
you be more specific on what type of problems you observe with prolonged 
medicine?

            
A.        Well, 
the most common side effect from a drug administration pump is 
constipation.  The next most common 
thing that we see is a sense of underlying nausea, and not so much pain in the 
stomach as lack of  loss of appetite, subtle feeling of them being nauseated or 
ill all the time in terms of the GI tract.  
But the most common finding is constipation.

            
Q.        Do 
you have an opinion as to the mechanism or why these medicines cause these types 
of problems?

            
A.        
Yeah.  They decrease gastric 
motility fairly dramatically in some people.

            
Q.        Is 
that recognized pretty readily through the pain medicine specialists or is that 

            
A.        Yes, 
usually.  Depends on level of 
suspicion, I suppose.

            
Q.        So 
that's  you don't believe that you're the minority to feel that way then.  Is that correct?

            
A.        
No.  No, I'm definitely not 
the minority.

            
Q.        Is 
this specific medications, Doctor?

            
A.        Well, 
it's more classes of medications.  
The opioid analgesics, the narcotic analgesics that are used in the pump 
are the biggest offender for these. . . .

            
Q.        
Doctor, you keep mentioning pump.  
Can oral pain medications cause the same gastric 
problem?

            
A.        
Yeah.  Yes, the side effect 
spectrum is identical between oral and intrathecal medication.  

 
 
[¶26]   The Medical Commission's order 
fixated on the timing and effects of one particular pain medication, 
Fiorinal.  While we do not suggest 
that Dr. Oakley's opinions had to be accepted by the Medical Commission, the 
opinions are clearly material to the question whether an isolated medication, 
Fiorinal, caused some or all of Rodgers' problems, or whether a class of 
narcotic medications caused the problems, and the opinions therefore should have 
at least been considered.  This 
Court will not infer from the fact that the evidence was presented and not 
recited in the Medical Commission's order that the Medical Commission simply 
rejected the evidence. The Medical Commission, as hearing examiner, has a duty 
to explicitly explain what weight, if any, it gives evidence, and why.  See Decker, ¶¶ 33-34, 124 P.3d at 696-97; Pan Am., 446 P.2d  at 
554-55.

 
 
[¶27]   Perhaps even more striking are the 
opinions not discussed in the Medical Commission's order that bear directly on 
the question of the cause of Rodgers' gastrointestinal problems.  For example, Dr. Oakley provided several 
opinions concerning the cause of Rodgers' gastrointestinal 
condition:

 
 
            
Q.        . . . 
Do you have an opinion as to whether Milton's gastrointestinal problems are caused 
by his pain medicine?

            
A.        I 
think a lot of his gastrointestinal problems have been actually caused by his 
medication.  There's been a lot of 
manipulations of medications over the years, and it's my opinion that the 
medications have directly contributed to his gastrointestinal problem.  

 
 
* * * 
*

 
 
            
Q.        So I 
guess I should ask you, do you have an opinion whether Mr. Rodgers' current 
gastritis was caused by this spinal stroke?

            
A.        No, I 
don't think so.  I think it's more a 
direct result of the medications for his chronic pain.  

 
 
* * * 
*

 
 
            
Q.        Other 
than his medicine, his pain medicine, what are the other things that would cause 
his gastrointestinal problems?

            
A.        Well, 
I mean, I suppose he could have an ulcer from other reasons or something like 
that.  I mean, you know, people who 
are on pain medicine get sick as well.  
It's unlikely that it's something like an influenza or a virus or 
something which is self-limited.  It 
was kind of an ongoing problem for him, and it would seem to be related more to 
the drugs than to any kind of infectious disease or other things that we would 
think of.  And, in fact, some of 
these drugs can also cause ulcer problems as well.  

 
 
* * * * 

 
 
            
Q.        So 
when we boil this all down, we really do speculate on this gastrointestinal 
problem being related to his work injury.

            
A.        
Yes.  You try to manipulate 
the drugs and see if it goes away, but unfortunately in his case it's a balance 
between the medicine we give him and not being able to really stop them, so we 
haven't been able to really test the theory.  

 
 
[¶28]   Dr. Kuckel likewise testified 
concerning causation, providing opinions on the causes of both Rodgers' 
gastrointestinal problems as well as his esophageal stricture.  While the Medical Commission's order 
quoted sparingly from Dr. Kuckel's examination notes and his deposition 
testimony, the following material opinions are absent from the Medical 
Commission's findings:

 
 
            
Q.        And 
again, under your impressions, could you give me your impressions according to 
that document?

            
A.        
Secondary to the medications that he was taking, I had thought that he 
had symptoms of what was called gastroparesis secondary to his pain 
medications.  Pain medications, 
narcotics, just about every single one of them, with the exception of a 
medication he is not on, will cause slowdown of contractions in the 
gastrointestinal tract.  What will 
happen is there will be no forward motion of food or secretions or acid, and I 
felt that his problems were secondary to that.

            
When I had gone and done some of his procedures, although it was not 
readily obvious in the reports, there were times when there were some retained 
contents which would not have been there had this patient had normal 
gastroparesis.  So my assumption was 
presumptively and with good reason that his chronic use of narcotic medications 
was causing gastroparesis.  He was 
retaining food secretions and acid, and these acids, secondary to his hiatal 
hernia and other complications, were refluxing back into his esophagus.  He was structuring down, and this 
necessitated me to perform esophageal dilatations on him in order for him to eat 
properly.  

 
 
* * * 
*

 
 
            
Q.        Now, 
as you testify today, do you have, I guess, a medical opinion as to what you 
believe causes his gastrointestinal problems?

            
A.        At 
the time when I saw him, part of his dyspeptic symptoms were caused by H. 
pylori.  H. pylori as an infection 
is implicated in causing acid peptic disease and is implicated in causing 
ulcers.  However, it is not 
implicated in causing gastroparesis. It is not implicated in causing 
gastroesophageal reflux disease and strictures, so part of his dyspeptic 
symptoms and part of his pain and I say a small portion of that was caused by 
that, but once that was treated, that was eliminated.  His problems were directly caused by his 
 were triggered and I think maintained by his pain medications resulting in 
gastroparesis, and therefore, he could not clear his acids.  

 
 
* * * 
*

 
 
            
Q.        
Doctor, you briefly hit on this, I know, but could you explain to me in 
detail more how you believe pain medications can cause this type of 
problems?

            
A.        
Sure.  Pain medications in 
general are CNS depressants, and one of the effects that pain medications have 
are decreased motility of the gastrointestinal tract.  In particular, the large intestine as 
well as the stomach have decreased motility.  This is evidenced by many people who 
have chronic narcotic use and/or abuse are extremely constipated.  People with chronic narcotic use and 
abuse have what they call gastroparesis.  
The stomach does not empty in a timely manner.  Gastric emptying time is directly 
reduced almost directly in proportion to amount and duration of narcotic agents 
used.

            
Of course, it depends on which kind of narcotic agents you're using.  Some are stronger than others, but in 
his case, he was on multiple agents and his ability to clear the  clear his 
gastric contents is severely compromised.  

 
 
* * * 
*

 
 
            
Q.        Do 
you have an opinion as to what caused this stricture?

            
A.        My 
opinion as to what caused the stricture is that reflux of acid and gastric 
contents up into the esophagus as they were not cleared would cause the 
stricture.  Continuous acid bathing 
on the distal portion of the esophagus is well documented in causing esophageal 
strictures. 

 
 
* * * * 

 
 
            
Q.        And 
that stricture is caused by the pain medicine he takes?

            
A.        
No.  The pain medication in 
and of itself does not cause it.  
The pain medication causes gastroparesis, a slowdown in the clearing of 
the stomach.  And therefore, the 
acid and anything that is left inside the stomach will reflux.  It has to go somewhere.  

 
 
[¶29]   The above-quoted opinions are 
clearly material to the issues before the Medical Commission, and we find their 
absence from the Medical Commission's order inexplicable.  The Division nonetheless argues the 
Medical Commission's order reflects a careful consideration and weighing of the 
material evidence in this case, first, because the order itself states the 
Medical Commission performed "a careful review of all the evidence presented in 
the case," and, second, because the order references evidence from Drs. Smith, 
Tietjen, McElwee, Kuckel, and Perakos.  
We disagree.  If an agency 
does not provide detailed findings of fact outlining the material evidence 
received and considered and some explanation for the weight or lack thereof 
given that evidence, this Court has no meaningful way to assess the agency's 
"careful review" of the evidence.  
See Decker, ¶ 34, 124 P.3d  at 697.  Furthermore, although the Medical 
Commission undoubtedly reviewed the voluminous medical records in this case, and 
the testimony of the deposed physicians, the absence of material opinions from 
the Medical Commission's findings of fact illustrates the incomplete 
consideration the Medical Commission gave the evidence.  The Division's citation in its appellate 
brief of evidence that was presented to the Medical Commission but not included 
in its order only highlights the order's deficiencies.   If the evidence were material, it 
should have been included in the findings of fact.  As we have repeatedly 
cautioned:

 
 
Appellate 
briefing is not the place to articulate sufficient findings of fact.  It is not the duty of this court to 
analyze and assess evidence presented to an administrative body to determine the 
weight to be given evidence or the credibility to be afforded 
witnesses.

 
 

Decker, ¶ 35, 
124 P.3d  at 697 (quoting Bush, ¶ 11, 
120 P.3d  at 180 (quoting Billings v. 
Wyoming Bd. of Outfitters and Guides, 2001 WY 81, ¶ 19, 30 P.3d 557, 567 
(Wyo. 2001))).  

 
 
[¶30]   Because the Medical Commission 
omitted material evidence from its findings of fact, its decision is arbitrary 
and capricious and must be reversed.  
See Olivas, ¶ 16, 130 P.3d  at 485; Decker, ¶ 24, 124 P.3d  at 694; Padilla, ¶ 6, 84 P.3d  at 
962.

 
 
 
 
Failure 
to Make Basic Findings of Fact

 
 
[¶31]   When reviewing Division decisions, 
the Medical Commission is acting in the capacity of a hearing examiner.  Wyo. Stat. Ann. § 27-14-616(b)(iv) (LexisNexis 
2005).  We have long held that a 
hearing examiner must

 
 
make 
findings of basic facts upon all of the material issues in the proceeding and 
upon which its ultimate findings of fact or conclusions are based.  Unless that is done there is no rational 
basis for review.

 
 

Decker, ¶ 27, 
124 P.3d  at 695 (quoting Bush, ¶ 9, 
120 P.3d at 180) (quoting Pan Am., 
446 P.2d at 555)).

 
 
[¶32]   The Wyoming APA, in particular Wyo. 
Stat. Ann. § 16-3-110 (LexisNexis 2005), requires more than a mere recitation of 
evidence or ultimate conclusions.  
It requires

 
 
findings 
of basic facts upon all material issues in the proceeding and upon which the 
ultimate findings of fact or conclusions are based.  FMC v. Lane, 773 P.2d 163 (Wyo. 1989).  In Cook v. Zoning Board of Adjustment for the 
City of Laramie, 776 P.2d 181, 185 (Wyo. 1989), we stated:  

 
 
It is 
insufficient for an administrative agency to state only an ultimate fact or 
conclusion, but each ultimate fact or conclusion must be thoroughly explained in 
order for a court to determine upon what basis each ultimate fact or conclusion 
was reached.  The court must know 
the why.  Geraud v. Schrader, 531 P.2d 872, 879 
(Wyo.), cert. denied sub nom.  Wind River Indian Education Association, 
Inc. v. Ward, 423 U.S. 904, 96 S. Ct. 205, 46 L. Ed. 2d 134 (1975).  

 
 

Himes v. 
Petro Engineering & Const., 2003 
WY 5, ¶ 19, 61 P.3d 393, 399 (Wyo. 2003) (quoting Mekss v. Wyoming Girls' School, State of 
Wyo., 813 P.2d 185, 201-02 (Wyo. 1991), cert. denied, 502 U.S. 904, 96 S. Ct. 205, 46 L. Ed. 2d 134 (1992)).            

 
 
[¶33]   To comply with the Wyoming APA, an 
administrative decision must begin with a complete recitation of basic 
facts.  Basic facts are the 
"historical and narrative events elicited from the evidence presented at trial, 
admitted by stipulation, or not denied, where required, in responsive 
pleadings."  Basin Elec. Power Coop., Inc. v. Dep't of 
Revenue, 970 P.2d 841, 850 (Wyo. 1998) 
(quoting Union Pacific R.R. Co. v. Bd. of 
Equalization, 802 P.2d 856, 860 (Wyo. 1990)).  Basic facts form the foundation for 
ultimate facts and must explain the basis for ultimate facts and 
conclusions.  Cotton v. McCulloh, 2005 WY 159, ¶ 40, 
125 P.3d 252, 265 (Wyo. 2005).  We 
will defer to basic facts if supported by substantial evidence and will affirm 
the agency's decision if the ultimate facts and legal conclusions logically and 
reasonably flow from those basic facts.  
Pan Am., 446 P.2d  at 555.  "When an agency does not set forth the 
reasons for its actionsthat is, when its findings are conclusorythis Court 
cannot uphold its decision."  Cotton, ¶ 40, 125 P.3d  at 
265.

 
 
[¶34]   The Medical Commission's decision 
contains findings of fact that qualify as basic facts, but they are very few and 
are inadequate to explain the conclusory ultimate facts upon which the Medical 
Commission based its decision.  For 
example, the Medical Commission's decision failed to make basic findings of 
fact, citing evidence or opinions from the record, that would support the 
following conclusory findings:

 
 
It is 
medically reasonable to conclude that Mr. Rodgers [sic] medical situation was 
aggravated initially by the erosive gastritis caused by his aspirin based 
medications.  His situation was 
substantially different after August of 2002, however, when his medication use 
had been change [sic] to eliminate Fiorinal and the esophageal obstruction 
didn't appear until October 2002.  
Had the medications been responsible for the esophageal stricture, we 
would expect that the stricture would have appeared far earlier than it 
did.  

 
 
* * * 
*

 
 
            
We further find that the evidence submitted herein supports a finding 
that Mr. Rodger's [sic] treatment for chronic gastritis through August 2002 is 
directly and causally related to the multitudes of medications he was prescribed 
by a variety of physicians to deal with chronic spine pain that was directly 
caused by his work injury and its' [sic] subsequent care and treatment from 21 
separate surgeries.  Mr. Rodgers' 
medical care and treatment for his esophageal stricture has not been proven to 
be related, either directly or indirectly, to his narcotic medicine usage and 
his gastrointestinal problem [sic] are related to the presence of H. pylori, was 
first discovered in October of 2002 by Dr. Kuckel, and is not caused by the work 
injury or medications taken for the work injury.  

 
 
[¶35]   Specifically, the Medical 
Commission's decision cites no evidence or medical opinions and makes no basic 
findings to support its conclusion that Rodgers' condition changed substantially 
after August 2002 or to explain the conclusion that had the narcotic medications 
been responsible for the esophageal stricture, it would have appeared 
earlier.  Likewise, the decision 
cites no evidence or opinions and makes no basic findings to explain its 
conclusion that all of Rodgers' gastrointestinal problems after 2002 were caused 
by the presence of H. pylori.  It is 
a leap from a basic finding that Rodgers tested positive for H. pylori to the 
conclusion that the presence of H. pylori caused all of Rodgers' 
gastrointestinal problems after 2002.  
The Medical Commission's decision provides no explanation of how it made 
that leap.  

 
 
[¶36]   An agency must make findings of 
basic fact on all material issues before it and upon which ultimate findings of 
fact or conclusions are based in order to enable the reviewing court to 
determine whether evidence was considered on a reasonable and proper basis.  Pan Am., 446 P.2d  at 555.  The Medical Commission's failure to do 
that in this case makes its decision arbitrary and capricious.  See Decker, ¶ 24, 124 P.3d  at 694; Padilla, ¶ 6, 84 P.3d  at 
962.

 
 
 
 
 
 
 
 
 
 

Improper 
Judicial Notice of a Contested Fact

 
 
[¶37]   An issue that the Medical 
Commission identified as material was the date on which Rodgers' esophageal 
stricture first presented itself.  
In rejecting as evidence of an earlier stricture a "Schatzki's ring" that 
was identified by an upper endoscopy performed on July 9, 2001, the Medical 
Commission made the following finding:

 
 
This 
Panel notes that a Schatzki's ring is also known as a lower esophageal ring and 
generally consists [of] thin rings of tissue that occur in the lower (distal) 
esophageal junction and is generally associated with hiatal hernia and is not 
caused by reflux. 

 
 
The 
record contains no information describing a Schatzki's ring or its cause, and 
Rodgers therefore argues that the Medical Commission improperly took judicial 
notice of a contested fact when it made this finding.  We agree.

 
 
[¶38]   Wyo. Stat. Ann. § 16-3-108(d) 
(LexisNexis 2005) addresses an agency fact finder's authority to take notice of 
certain facts.  It 
provides:

 
 
            
Notice may be taken of judicially cognizable facts.  In addition notice may be taken of 
technical or scientific facts within the agency's specialized knowledge or of 
information, data and material included within the agency's files.  The parties shall be notified either 
before or during the hearing or after the hearing but before the agency decision 
of material facts noticed, and they shall be afforded an opportunity to contest 
the facts noticed.

 
 
In 
addition to the requirements of § 108(d), this Court has held that an 
administrative agency should take judicial notice only of facts that are not 
subject to reasonable dispute.  Heiss v. City of Casper Planning and Zoning Comm'n, 941 P.2d 27, 31 
(Wyo. 
1997).

 
 
[¶39]   The Medical Commission's 
above-quoted finding was inappropriate for two reasons.  First, as reflected in the medical 
sources quoted in Rodgers' brief, the etiology of a Schatzki's ring is not a 
fact that is not subject to reasonable dispute.  See Winters, G. et al., Schatzki's Rings do not protect against acid 
reflux and may decrease esophageal acid clearance, 2003 Dig. Disease: Feb.; 
48(2):299 ("the etiology of [Schatzki's] rings is as unclear today as when 
Templeton first described them in 1944. . . . There are three main theories of 
development . . . the last, and most popular, theory is the inflammatory theory, 
which attributes ring formation to acid reflux into the esophagus.").  Second, the Medical Commission did not 
provide notice to the parties of the material facts noticed or allow the parties 
an opportunity to contest the facts noticed as required by § 
108(d).

 
 
[¶40]   The Division argues that the 
Schatzki's ring finding was appropriate because the Medical Commission's rules 
authorize it to make findings based on the panel's experience, technical 
competence and specialized knowledge.  
In particular, Chapter 10, Section 3(a) of the rules of the Medical 
Commission provides:

 
 
            
The medical hearing panel shall make and enter a written decision and 
order containing findings of fact and conclusions of law, separately 
stated.  The findings of fact shall 
be derived from the evidence of the record in the proceeding, matters officially 
noticed in that proceeding, and matters within the medical hearing panel's 
knowledge as acquired through performing its functions and duties.  Such findings shall be based on the kind 
of evidence on which reasonably prudent persons are accustomed to rely upon the 
conduct of their serious affairs, even if such evidence would be inadmissible in 
a civil trial.  The 
medical hearing panel's experience, technical competence and specialized 
knowledge may be utilized in evaluating the evidence.  

 
 
Rules 
and Regulations, Wyoming Medical Comm'n, Workers' Comp. Div. ch. 10, § 3(a) 
(Feb. 14, 2003) (emphasis added).

 
 
[¶41]   We disagree that this provision 
authorizes a Medical Commission panel to take notice of any material fact within 
its expertise regardless of whether the fact is subject to reasonable dispute 
and without following the procedure set forth in § 16-3-108(d).  The plain terms of Chapter 10, Section 
3(a) require that the panel's findings of fact be derived from the record.  The highlighted sentence of the rule 
merely acknowledges that a Medical Commission panel brings expertise to its 
evaluation of medical evidence and opinions.  As we observed in Decker, we anticipate that the Medical 
Commission's expertise will assist it in evaluating evidence, but the Medical 
Commission's decisions must still comply with the Wyoming APA.  Decker, ¶¶ 33-34, 124 P.3d at 696-97; see also Jackson v. State ex rel. Wyoming 
Workers' Safety and Comp. Div., 786 P.2d 874, 878-79 (Wyo. 1990) (agency 
hearing procedures must comply with the Wyoming APA).  In making its Schatzki's ring finding 
the Medical Commission took notice of a contested material fact without 
following the procedures set forth in the Wyoming APA.  The finding is therefore arbitrary and 
capricious.  See Decker, ¶ 24, 124 P.3d  at 694; Padilla, ¶ 6, 84 P.3d  at 962.1

Medical 
Commission's Decision as Arbitrary and Capricious

 
 
[¶42]   As we noted at the outset of this 
opinion, when confronted with an agency decision that has failed to address all 
material evidence and make findings of fact that enable meaningful review, it is 
this Court's preference to remand for entry of a new order.  

 
 
If the 
record before the agency does not support the agency action, if the agency has 
not considered all relevant factors, or if the reviewing court simply cannot 
evaluate the challenged agency action on the basis of the record before it, the 
proper course, except in rare circumstances, is to remand to the agency for 
additional investigation or explanation.  
The reviewing court is not generally empowered to conduct a de novo inquiry into the matter being 
reviewed and to reach its own conclusions based on such an 
inquiry.

 
 

Bush, ¶ 12, 
120 P.3d  at 181 (quoting Florida Power 
& Light Co. v. Lorion, 470 U.S. 729, 744, 105 S. Ct. 1598, 1607, 
84 L. Ed. 2d 643 (1985)).  This Court 
is particularly reluctant to overturn a hearing examiner's determinations of the 
credibility and weight to be given evidence and will do so only when the 
determinations are "clearly contrary to the overwhelming weight of the 
evidence."  Olivas, ¶ 17, 130 P.3d  at 485; Taylor v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2005 WY 148, ¶ 8, 123 P.3d 143, 146 (Wyo. 2005); Brierley v. State ex rel. Wyoming Workers' 
Safety & Comp. Div., 2002 WY 121, ¶ 16, 52 P.3d 564, 571 (Wyo. 2002).

            

[¶43]   This case presents circumstances 
that justify this Court in taking the rare steps of, first, overturning the fact 
finder's determination of the weight to be given a medical opinion, and, second, 
reversing with directions to enter an order awarding benefits.  For the reasons that follow, we hold 
that the Medical Commission's reliance on the opinion of Dr. Perakos was 
arbitrary and capricious.  We 
further hold that the Medical Commission's decision to deny benefits is 
arbitrary and capricious because it is based on inaccurate findings of fact and 
is contrary to the overwhelming weight of the evidence.

 
 
[¶44]   At the Division's direction, 
Rodgers submitted to an IME by Dr. Perakos.  Based on that IME and a review of some 
of Rodgers' records, Dr. Perakos provided the following opinion with which the 
Medical Commission agreed and upon which it in part based its decision: 

As we do 
not have most of Dr. Tietjen's records I cannot be convinced that there is a 
causal relationship between his medications and causing his esophageal 
strictures or dysmotility of his esophagus, particularly in the setting of a 
normal esophageal motility study obtained by Dr. McElwee within the past two 
years.  Based upon the information 
we have to a reasonable degree of medical probability there is not a probable 
causal relationship between the current complaint and the medications used . . . 
.

 
 
[¶45]   Dr. Tietjen treated Rodgers for his 
gastrointestinal problems from April 1997 through April 2000.  The absence of most of his records from 
Dr. Perakos' review creates a sizable gap in the history on which Dr. Perakos 
based his opinion, as Dr. Perakos himself acknowledged in his IME 
report:

 
 
I next 
have a difficulty making a direct association with other medications possibly 
causing his stricture.  As I do not 
have good copies of the photos taken by Dr. Kuckel and I do not have the primary 
documents from Dr. McElwee, and I have virtually no documents from Dr. Tietjen, 
it is hard to put this together.  I 
suspect, however, that it would be a big leap to tie medications with the 
stricture. 

 
 
[¶46]   The incomplete medical history upon 
which Dr. Perakos based his opinion in itself raises serious questions 
concerning the reliability of that opinion.  We are not, however, left to guess at 
the deficiencies created by the incomplete history.  Dr. Perakos based his opinion in this 
case on the assumption that Rodgers did not suffer from gastric outlet 
obstruction and additionally that Rodgers did not suffer from acid reflux.  He testified as 
follows:

 
 
            
Q.        And 
would you disagree that his gastroparesis is caused by the same 
medicine?

            
A.        No, I 
wouldn't necessarily disagree in that gastroparesis is, as I said earlier, the 
narcotics will slow down the motion of stomach contents, contents of the small 
intestine, the contents of the large intestine, so that you can have a slowing 
of the motility or the actual contractions or peristalsis anywhere in the 
gastrointestinal tract from narcotics, so I will not 
disagree.

            
Q.        But 
you would disagree to make the next leap that the esophageal stricture is caused 
by that?

            
A.        That 
is correct.  If, and I believe I 
said this earlier, if Mr. Rodgers had a gastric outlet obstruction, which he 
does not have, either at the time of Dr. Tietjen's examination or at the time of 
Dr. Kuckel's examination, if he had a gastric outlet obstruction, then you can 
visualize a large volume of material sitting in the stomach, not going anywhere 
except the one way that is open, and that is in the wrong direction, and that 
just isn't the case. 

 
 
[¶47]   Of course, as the Medical 
Commission observed, Rodgers did in fact suffer from a gastric outlet 
obstruction and had Dr. Perakos had Rodgers' complete medical history he would 
have had that information.  
Additionally, in his IME report, Dr. Perakos stated that "[i]f Mr. 
Rodgers does have significant gastroesophageal reflux disease then that can 
contribute to worsening of the esophageal stricture."  The record is also clear that Rodgers 
suffers from reflux.  It is apparent 
that the information Dr. Perakos was missing would have changed his opinion from 
"I suspect, however, that it would be a big leap to tie medications with the 
stricture," to an opinion similar to that of Dr. Kuckel's:  the narcotic medications caused 
gastroparesis, a large volume of material was left sitting in Rodgers' stomach 
with no where to go but up, and the reflux caused the esophageal stricture.  

 
 
[¶48]   Given the incomplete medical 
history and flawed assumptions on which Dr. Perakos based his opinion, we find 
the Medical Commission's reliance on the opinion arbitrary and capricious.  The Medical Commission did not, however, 
base its decision entirely on the opinion of Dr. Perakos.  The Medical Commission also based its 
decision in part on the opinion of Dr. Kuckel and in part on its finding that 
"[h]ad the medications been responsible for the esophageal stricture, we would 
expect that the stricture would have appeared far earlier than it did."  It is the inaccuracies in the Medical 
Commission's findings concerning the opinion of Dr. Kuckel that further compel 
us to find the Medical Commission's decision arbitrary and 
capricious.

 
 
[¶49]   The Medical Commission found Dr. 
Kuckel's opinion persuasive because he is board certified in internal medicine 
and board-eligible in gastroenterology.  
The concern we have with the Medical Commission's reliance on Dr. 
Kuckel's opinion is not with the credibility of Dr. Kuckel's opinion, but that 
the Medical Commission misstated his opinion.  The Medical Commission found as follows 
concerning Dr. Kuckel's opinion (emphasis in original):

 
 
Dr. 
Kuckel is Board Certified in internal medicine and board-eligible in 
gastroenterology and was unequivocal in his opinion that the variety of 
medications being taken by Mr. Rodgers were the primary causative agent of his 
gastrointestinal problems.  Dr. 
Kuckel described Mr. Rodgers as taking "prodigious doses of narcotics."  (Kuckel Deposition, p. 
30)

 
 
            
In response to his attorney's question, ". . . real quickly Doctor, his 
condition, his dysphagia, gastritis, duodenitis, and gastroparesis, do you 
believe that all of these are caused by or are secondary to his use of pain 
medication?"  Dr. Kuckel replied, "I 
believe that this is the case, yes."  
(Kuckel deposition, page 22)  
We agree with Dr. Kuckel's conclusions regarding those issues, but note 
that he was NOT questioned on the espohagitis, hiatal hernia, esophageal 
stricture, esophageal dilation and Schatzki's ring are not mentioned in his 
opinion, and we find that those conditions are not related to his narcotic pain 
medication usage. 

 
 
[¶50]   We find the Medical Commission's 
reading of the above-quoted opinion of Dr. Kuckel to be strained and 
narrow.  The inclusion of the terms 
dysphagia (difficulty swallowing), gastritis and gatroparesis in the causation 
question arguably covered the gamut of Rodgers' complaints.  More importantly, though, the statement 
that Dr. Kuckel was not questioned concerning Rodgers' esophagitis and 
esophageal stricture is simply wrong.  
Dr. Kuckel was repeatedly questioned concerning these conditions and 
repeatedly gave an unequivocal opinion that Rodgers' pain medications were the 
ultimate cause of these conditions.  
For example:

 
 
            
Q.        And 
again, under your impressions, could you give me your impressions according to 
that document?

            
A.        
Secondary to the medications that he was taking, I had thought that he 
had symptoms of what was called gastroparesis secondary to his pain 
medications.  Pain medications, 
narcotics, just about every single one of them, with the exception of a 
medication he is not on, will cause slowdown of contractions in the 
gastrointestinal tract.  What will 
happen is there will be no forward motion of food or secretions or acid, and I 
felt that his problems were secondary to that.

            
When I had gone and done some of his procedures, although it was not 
readily obvious in the reports, there were times when there were some retained 
contents which would not have been there had this patient had normal 
gastroparesis.  So my assumption was 
presumptively and with good reason that his chronic use of narcotic medications 
was causing gastroparesis.  He was 
retaining food secretions and acid, and these acids, secondary to his hiatal 
hernia and other complications, were refluxing back into his esophagus.  He was structuring down, and this 
necessitated me to perform esophageal dilatations on him in order for him to eat 
properly.  

 
 
* * * 
*

 
 
            
Q.        Now, 
as you testify today, do you have, I guess, a medical opinion as to what you 
believe causes his gastrointestinal problems?

            
A.        At 
the time when I saw him, part of his dyspeptic symptoms were caused by H. 
pylori.  H. pylori as an infection 
is implicated in causing acid peptic disease and is implicated in causing 
ulcers.  However, it is not 
implicated in causing gastroparesis.  
It is not implicated in causing gastroesophageal reflux disease and 
strictures, so part of his dyspeptic symptoms and part of his pain and I say a 
small portion of that was caused by that, but once that was treated, that was 
eliminated.  His problems were 
directly caused by his  were triggered and I think maintained by his pain 
medications resulting in gastroparesis, and therefore, he could not clear his 
acids.  

 
 
* * * * 

 
 
            
Q.        
Doctor, you briefly hit on this, I know, but could you explain to me in 
detail more how you believe pain medications can cause this type of 
problems?

            
A.        
Sure.  Pain medications in 
general are CNS depressants, and one of the effects that pain medications have 
are decreased motility of the gastrointestinal tract.  In particular, the large intestine as 
well as the stomach have decreased motility.  This is evidenced by many people who 
have chronic narcotic use and/or abuse are extremely constipated.  People with chronic narcotic use and 
abuse have what they call gastroparesis.  
The stomach does not empty in a timely manner.  Gastric emptying time is directly 
reduced almost directly in proportion to amount and duration of narcotic agents 
used.

            
Of course, it depends on which kind of narcotic agents you're using.  Some are stronger than others, but in 
his case, he was on multiple agents and his ability to clear the  clear his 
gastric contents is severely compromised.

 

* * * * 

            
Q.        Do 
you have an opinion as to what caused this stricture?

            
A.        My 
opinion as to what caused the stricture is that reflux of acid and gastric 
contents up into the esophagus as they were not cleared would cause the 
stricture.  Continuous acid bathing 
on the distal portion of the esophagus is well documented in causing esophageal 
strictures. 

 
 
* * * * 

 
 
            
Q.        And 
that stricture is caused by the pain medicine he takes?

            
A.        
No.  The pain medication in 
and of itself does not cause it.  
The pain medication causes gastroparesis, a slowdown in the clearing of 
the stomach.  And therefore, the 
acid and anything that is left inside the stomach will reflux.  It has to go 
somewhere.

 
 
[¶51]   The Medical Commission's finding 
that Dr. Kuckel did not provide an opinion concerning the cause of Rodgers' 
esophagitis and esophageal stricture was clearly erroneous.  The conclusion the Medical Commission 
drew from that erroneous finding, that these conditions were not related to 
Rodgers' narcotic pain usage, is therefore arbitrary and capricious.  

 
 
[¶52]   Although we have rejected the 
Medical Commission's reliance on Dr. Perakos' opinion, we do not otherwise need 
to reweigh any evidence to reach our conclusion that the order denying benefits 
must be reversed and an order awarding benefits be entered.  The Medical Commission accepted the 
opinion of Dr. Kuckel as persuasive but then misstated the opinion.  We likewise accept Dr. Kuckel's opinion 
as persuasive, and, through our decision, we simply give effect to that 
opinion.  

 
 
 
 
CONCLUSION

 
 
[¶53]   Based on Dr. Kuckel's opinion, 
Rodgers' use of narcotic pain medications to treat his chronic back pain caused 
his gastrointestinal problems which caused his esophageal stricture.  Only a "small portion" of Rodgers' 
condition is related to the presence of H. pylori which all parties agree is not 
related to the pain medications.  We 
therefore reverse the order of the district court and remand with directions to 
vacate the order denying benefits.  
Further, the district court is to remand the case to the Medical 
Commission for entry of an order awarding benefits for the diagnosis and 
treatment of Rodgers' gastrointestinal problems and esophageal stricture, with 
the exception of any costs related solely to the treatment of Rodgers for the 
presence of H. pylori.

 
 
 
 

FOOTNOTES

   1The Division 
cites to evidence in the record from which it argues the Medical Commission 
could have drawn its finding concerning the Schatzki's ring.  At the risk of being repetitive, we wish 
to emphasize that appellate briefing is not the appropriate place to articulate 
basic facts to support an agency's conclusions.  See Decker, ¶ 35, 124 P.3d  at 697.  Furthermore, we are at a loss to see how 
the evidence the Division cites would in fact support the Medical Commission's 
Schatzki's ring finding.  The facts 
the Division cites are results from an upper GI series performed by Dr. Kuckel 
noting a "[p]robable obstructive Schatzki's ring."   The report itself says nothing 
concerning the Schatzki's ring etiology, but Dr. Kuckel later testified 
unequivocally that in his opinion the esophageal stricture was caused by reflux, 
which was caused by gastroparesis, which was caused by Rodgers' narcotic pain 
medication.