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

State: wyoming

Issuer: Wyoming Supreme Court

Document:

IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: DANIEL DECKER V. STATE OF WYOMING, ex rel., WYOMING MEDICAL COMMISSION; and WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2005 WY 160124 P.3d 686Case Number: 05-38Decided: 12/15/2005
OCTOBER 
TERM, A.D. 2005

 
 
IN THE 
MATTER OF THE WORKER'S

COMPENSATION 
CLAIM OF:

 
 
DANIEL 
DECKER,

 
 
Appellant

(Petitioner),

 
 
v.

 
 
STATE OF 
WYOMING, ex rel., WYOMING

MEDICAL 
COMMISSION; and WYOMING

WORKERS' 
SAFETY AND

COMPENSATION 
DIVISION,

 
 
Appellees

(Respondents).

 
 
Appeal 
from the DistrictCourtofLaramieCounty

 
 

Representing 
Appellant:

Bill G. 
Hibbler, Cheyenne, 
Wyoming

 
 

Representing 
Appellee:

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

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

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Daniel Decker 
alleges that he suffers from a condition that causes him upper body pain and 
that his employment as a sheet metal worker with Mountain Aire Heating and Air 
aggravated his condition.  The 
Wyoming Workers' Compensation Division (Division) denied Decker's claim for 
benefits, and Decker objected.  
After a contested case hearing, the Medical Commission Hearing Panel 
upheld the denial of Decker's claim on the grounds that Decker did not prove 
that he suffers from thoracic outlet syndrome or that his symptoms are otherwise 
related to his employment.  Decker 
appealed to the district court, which affirmed the Medical Commission's 
decision.  Decker now appeals to 
this Court.  This Court finds that 
the Medical Commission's order denying benefits is facially insufficient to 
permit review.  We therefore reverse 
the district court's decision and remand with directions to vacate the order 
denying benefits.

 
 
ISSUES

 
 
[¶2]      Decker presents 
two issues:

 
 

I.                     
Whether 
the Medical Commission order is supported by substantial 
evidence?

 
 

II.                   
Whether 
the Medical Commission order is contrary to law?

 
 
The 
Division presents the following single statement of the 
issue:

 
 
A 
claimant applying for workers' compensation benefits must prove that each 
additional claim is related to their employment injury.  The Medical Commission Hearing Panel 
determined that Decker's medical complaints of thoracic outlet syndrome were not 
related to a compensable work injury, which was diagnosed and reported as 
bilateral wrist tendinitis.  Is the 
Medical Commission Hearing Panel's decision denying benefits supported by 
substantial evidence?

 
 
FACTS

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

 
 
[¶4]      On August 27, 
2001, Decker was pulling a piece of tin out from under a bench and felt his 
wrist pop.  Shortly thereafter while 
snipping the corners of another piece of tin, Decker's other wrist popped and 
began to feel sore.  From Decker's 
reported date of injury to the date of his hearing before the Medical 
Commission, Decker was examined and/or treated by at least nine physicians and 
one psychologist, including two independent medical examiners.  We set forth below a fairly detailed 
account of the medical evidence presented to the Medical Commission, both to 
outline the varying medical opinions and to provide a backdrop for the necessary 
findings of fact we find missing from the Medical Commission's 
decision.

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

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

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

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

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

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

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

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

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

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

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

 
 
* * * * 

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

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

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

 
 
* * * * 

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

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

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

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

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

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

 
 
By 
letter dated March 29, 2002, Dr. Annest provided his opinion that Decker's 
complaints "are work related complaints which resulted from his work as a sheet 
metal worker for Mountain Air Heating Company."1 

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

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

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

 
 
* * * * 

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

 
 
* * * * 

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

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

 
 
My 
recommendation is that he see a rheumatologist.[2]  
The history of joint pains is not compatible with thoracic outlet 
syndrome.  I have also suggested 
that he needs to have a CT of the thoracic outlet using our 
protocol.

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

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

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

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

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

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

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

 
 
* * * 
*

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

 
 
* * * * 

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

 
 
[¶19]   Following the contested case 
hearing during which the Medical Commission was provided medical reports, Dr. 
Schabauer's deposition testimony, and Decker's testimony, the Medical Commission 
issued its order which contained thirteen findings of fact.  The first twelve findings of fact appear 
to be findings of basic fact, or a recitation of some of the evidence presented 
to the Commission.  Paragraph 13 of 
the findings of fact appears to contain the Commission's findings of ultimate 
fact.  It 
provides:

 
 
            
The Panel finds the initial injury reported of wrist tendinitis was 
likely accurate.  He was engaged in 
physical activities which resulted in a "popping" in his wrists followed by 
pain.  While seeing Dr. Johnson, 
pressure or movements of the wrist caused pain.  If Mr. Decker was suffering from 
thoracic outlet syndrome, palpation or movement of the wrists would have no 
effect on his condition.  Wrist 
tendinitis does not cause thoracic outlet syndrome.  After being prescribed wrist splints by 
Dr. Johnson, Mr. Decker testified his condition progressively became worse and 
his symptoms moved up his arm.  
Wrist splints do not cause thoracic outlet syndrome no[r] would they have 
any effect one way or the other on such a condition.  Mr. Decker continued to follow up with 
Dr. Johnson for several months and noted no elbow, upper arm or shoulder 
problems.  Diffuse pain and numbness 
throughout the arms would be seen with thoracic outlet syndrome.  During this time period Mr. Decker was 
off work and then was working far less hours and light duty.  This would have helped symptoms of 
thoracic outlet syndrome and not caused them to increase.  It is unusual to have someone work light 
duty and have thoracic outlet syndrome symptoms get worse.  Mr. Decker worked in the same type of 
job for years without any symptoms.  
There is no medical explanation as why such a claimed condition would 
suddenly begin and continue to get worse.[FN]

 
 
FN The 
only possible explanation could be an increase in weight which has nothing to do 
with an occupational injury.  

 
 
From Mr. 
Decker's testimony and the records, the history of how these symptoms developed 
does not fit the normal presentation of thoracic outlet 
syndrome.

 
 
            
Physical findings of thoracic outlet syndrome such as reduced blood flow 
occur in nonsymptomatic persons.  
Further, the various doctors who have examined Mr. Decker report 
inconsistent physical findings.  
Most of these doctors, other than the independent examining physicians, 
did not have the opportunity to review the prior medical records and how the 
symptoms developed.  Further, there 
are normal EMG studies, generally normal vascular findings, and normal 
radiographic studies.  Also 
significant, Mr. Decker reports joint pain in his wrists, elbows, and 
shoulders.  Complaints of joint pain 
as opposed to diffuse pain, is not consistent with thoracic outlet 
syndrome.  Based on the evidence 
submitted, the Panel cannot conclude that Mr. Decker has thoracic outlet 
syndrome.  Further based on the 
evidence, the Panel cannot find whether the symptoms being experienced by Mr. 
Decker relate to his work effort on behalf of the Employer.  

 
 
[¶20] 
  Based on these findings, the 
Medical Commission held in its final conclusion of law that "Mr. Decker has not 
met his burden of proof that he has thoracic outlet syndrome.  Further, he has not met his burden of 
proof that whatever may be the cause of his symptoms that such is related to his 
employment." 

 
 
STANDARD 
OF REVIEW

 
 
[¶21]   A worker's compensation claimant 
has the burden of proving every essential element of his claim by a 
preponderance of the evidence.  Cramer v. State ex rel. Wyoming Workers' 
Safety and 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.

 
 
[¶22]   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.

[¶23]   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 and Comp. Div., 2005 WY 23, ¶ 7, 106 P.3d 867, 870 (Wyo. 2005); Newman v. State ex rel. Wyoming Workers' 
Safety and 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.

 
 
[¶24]   Even if sufficient evidence 
supports the administrative decision under the substantial evidence test, Newman requires that this Court apply 
the arbitrary-and-capricious standard as a "safety net" to catch other agency 
action that may have violated the Wyoming Administrative Procedures Act.  Loomer v. State ex rel. Wyoming Workers' 
Safety and 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."  Padilla v. State ex rel. Wyoming Workers' 
Safety and Comp. Div., 2004 WY 10, ¶ 6, 84 P.3d 960, 962 (Wyo. 2004).  

 
 
DISCUSSION

 
 
[¶25]   Decker argues the Medical 
Commission's decision should be reversed both because it is unsupported by 
substantial evidence and because it is contrary to law.  Because we find that the Medical 
Commission's findings of fact fail to provide this Court a rational basis for 
judicial review, we do not address Decker's substantial evidence arguments.  We agree with Decker that the 
Commission's findings of ultimate fact, in particular those found in Paragraph 
13 of its findings, appear to represent the Commission's personal impressions 
and opinion concerning Decker's condition rather than the required weighing of 
the relevant evidence presented to the Commission.  We will address first the deficiencies 
in the Medical Commission's findings of fact, and then, to provide guidance on 
remand, we will briefly address Decker's other contentions that the Medical 
Commission decision is contrary to law.

 
 

Findings 
of Fact

 
 
[¶26]   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).

 
 
[¶27]   We have interpreted § 16-3-110 to 
require more than a mere recitation of evidence or ultimate 
conclusions:

 
 
Our rule 
is that this statutory provision demands 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).

 
 

Mekss v. 
Wyoming Girls' School, State of Wyo., 813 P.2d 185, 201-02 (Wyo. 1991), cert. denied, 502 U.S. 1032, 112 S. Ct. 872, 116 L. Ed. 2d 777 (1992).

 
 

Himes, ¶ 19, 
61 P.3d  at 399.  We recently 
reiterated this same approach, holding 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 judicial review.

 
 
* * * * 

 
 
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.

 
 

Bush v. 
State ex rel. Wyoming Workers' Safety and Comp. Div., 2005 
WY 120, ¶ 9, 120 P.3d 176, 180 (Wyo. 2005) (quoting Pan Am. Petroleum Corp. v. Wyoming Oil and 
Gas Conservation Comm'n, 446 P.2d 550, 555, 557 (Wyo. 
1968)).

 
 
[¶28]   In this case, the order contains no 
indication the Medical Commission considered and weighed all material evidence 
offered by the parties.  The 
Commission concluded that Decker's original diagnosis of bilateral wrist 
tendinitis was probably correct, and that he did not prove he suffered from 
thoracic outlet syndrome or that his upper extremity symptoms arose out of his 
employment.  The Commission did not, 
however, explain how it weighed the conflicting medical opinions to reach these 
conclusions.  

 
 
[¶29]   The Commission's conclusion that 
the diagnosis of bilateral wrist tendinitis was probably correct illustrates our 
concern.  The original diagnosis of 
wrist tendinitis was made by Dr. Johnson, but Dr. Johnson did not hold to that 
diagnosis.  Within a short time, he 
explored other explanations for Decker's symptoms and eventually referred him 
for a second opinion.  The only 
physician that opined that bilateral wrist tendinitis was the correct diagnosis 
was Dr. Moress.  The Commission did 
not explain why it found Dr. Moress' opinion to be more persuasive or credible 
than any of the numerous other opinions in the record.  Likewise, only Dr. Moress definitively 
ruled out thoracic outlet syndrome as the cause of Decker's symptoms.  Dr. Moress did not see Decker until 
2004, over two years after the onset of Decker's symptoms, and Decker testified 
that Dr. Moress examined him for only ten minutes. The Commission may have an 
adequate explanation for accepting Dr. Moress' opinion and rejecting the 
numerous other medical opinions, but it has not provided an explanation and we 
therefore have no way of reviewing its decision.

 
 
[¶30]   The Medical Commission was 
presented with numerous medical opinions, most providing that Decker suffers 
from thoracic outlet syndrome or something similar, that his condition is 
congenital, and that his work aggravated his condition.  The Medical Commission decision is 
devoid of any weighing of these varying opinions.  The closest the Medical Commission came 
to weighing the medical evidence was in the second paragraph of its finding of 
fact number 13, where it stated concerns with inconsistent physical findings 
reported to the physicians and incomplete medical histories provided to all but 
the independent examining physicians.  
This observation is insufficient, however, to allow meaningful judicial 
review.  It does not specify the 
inconsistent physical findings or the gaps in history the Commission found 
material.  Without that specificity, 
this Court cannot evaluate the reasonableness of the Commission's assertions or 
its reliance on Dr. Moress' opinion.

 
 
[¶31]   Instead of weighing the medical 
opinions and other evidence, the Medical Commission appears to have 
independently diagnosed Decker based on symptoms reported by Decker and 
described in his medical records.  
Our concern that this was the Commission's approach is furthered by 
certain questions panel members asked Decker during the contested case 
hearing.  For 
example:

 
 
Q.        And 
when you first saw Dr. Johnson and he examined you, he writes that your wrists 
were tender to palpation; is that correct, when he would grasp them or pinch 
them in some way?  

 
 
Q.        Or if 
you moved your wrists in a particular direction, up or down or sideways, that it 
was also tender when he would do that? 

 
 
Q.        Now 
you currently state that you have continued numbness, and I guess that's in your 
hand or in your arms? 

 
 
Q.        Now 
can you just put your hands up and show me on each hand where it bothers 
you?  

 
 
Q.        Do 
you have pain on motion of your wrists currently?  

 
 
Q.        When 
it popped, was it just a pop or did you feel any tingling in your hand at the 
time? 

 
 
Q.        Now, 
did you feel that pop on the back of your wrist or on the - - the inside part, 
the palm side of your wrist?  

 
 
Q.        . . . 
Did you ever feel a tight feeling around your arms or did you experience -- 
tight feeling around your arms, around your neck, did you have any headaches 
during the time when you were felt to have thoracic outlet?  

 
 
[¶32]   We do not take issue with the 
Commission asking these types of questions if the responses assist them in some 
way in evaluating the evidence in the record.  Our concern is that the Commission, 
instead of weighing the medical evidence presented by the parties, used the 
information elicited in response to these questions to diagnose Decker.  The following findings illustrate our 
concern.  They do not reference any 
of the medical opinions presented to the Commission, and our review of the 
record found no medical opinions supporting them.

 
 
 "While seeing Dr. Johnson, pressure or 
movements of the wrist caused pain.  
If Mr. Decker was suffering from thoracic outlet syndrome, palpation or 
movement of the wrists would have no effect on his 
condition."

 
 
"After 
being prescribed wrist splints by Dr. Johnson, Mr. Decker testified his 
condition progressively became worse and his symptoms moved up his arm.  Wrist splints do not cause thoracic 
outlet syndrome no[r] would they have any effect one way or the other on such a 
condition."

 
 
"From 
Mr. Decker's testimony and the records, the history of how these symptoms 
developed does not fit the normal presentation of thoracic outlet 
syndrome."  

 
 
[¶33]   This Court recognizes the expertise 
the Medical Commission brings to medically contested cases and the value of the 
Commission's expertise in honing in on the critical evidence.  "The creation of the Medical Commission 
reflects the legislature's recognition that many contested claims involve 
complex medical issues, and in some cases, those issues are dispositive.  Thus, each medical hearing panel will 
have at least one physician, and all will be health care providers with the 
expertise to determine the medical issues before them."  French v. Amax Coal West, 960 P.2d 1023, 
1030 (Wyo. 
1998).  We have, however, also held 
that the Medical Commission's role, as fact finder, requires it to determine the 
weight to be given medical opinion testimony.  Hurley v. PDQ Transport, Inc., 6 P.3d 134, 138 (Wyo. 2000).  As with any 
hearing examiner, the Commission is charged with weighing the evidence and 
determining the credibility of witnesses.

 
 
"When 
presented with medical opinion testimony, the hearing examiner, as the trier of 
fact, is responsible for determining relevancy, assigning probative value, 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."

 
 

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, 329-30 (Wyo. 1999)).

 
 
[¶34]   As the hearing examiner in 
medically contested cases, the Medical Commission is tasked with weighing the 
medical and other evidence presented to it by the parties.  It is not tasked with providing the 
equivalent of an independent medical examination and opinion.  To allow a Medical Commission decision 
to rest on the medical opinions of a panel's members rather than on a weighing 
of the opinions submitted as evidence would be contrary to the Wyoming 
Administrative Procedure Act.  As 
this Court observed in Devous v. Wyoming 
State Bd. of Medical Examiners, 845 P.2d 408, 418 (Wyo. 
1993):

 
 
If 
judicial review has any purpose, it must be exercised by objectively evaluating 
evidence in the record.  There is no 
way that a judicial review could reach the subjective determination of standards 
by individual members of the Board.  
Consequently, in order to maintain the integrity of judicial review, we 
conclude it is necessary that, with respect to the violations that were asserted 
. . . , expert testimony in the record was required and, lacking such testimony, 
there is no substantial evidence to sustain those 
allegations.

 
 
In this 
case, the record does contain medical opinion evidence.  What is missing is the Commission's 
weighing of those opinions, and without that weighing, this Court has no basis 
for reviewing the reasonableness of the Commission's decision.  

 
 
[¶35]   In its brief, the Division points 
to much evidence in the record which it argues supports the Medical Commission's 
decision in this case.  We reject 
the Division's arguments.  The 
weighing of evidence to which the Division contends we must defer simply was not 
done by the Commission, and on appeal is not the appropriate time to weigh 
evidence.  

 
 
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.

 
 

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)).  

 
 
[¶36]   Because the Medical Commission's 
order fails to make findings that adequately explain the rationale for the 
Commission's decision, that order must be vacated.  

 
 
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)).  We 
therefore remand this matter to the Medical Commission for findings of 
supplemental facts and the entry of a new, more complete order either granting 
or denying benefits.

 
 

Burden 
of Proof

 
 
[¶37]   In a footnote to Paragraph 7 of its 
Conclusions of Law, the Medical Commission stated:

 
 
            
The Panel considered this issue under the standard burden of proof.  In all likelihood, it should be 
considered under the stricter burden of proof under W.S. §27-14-603(a) for 
claims based on injuries that occur over a substantial period of time.  Mr. Decker has not met his burden under 
either standard.

 
 
Decker 
argues the Medical Commission acted contrary to law in citing one standard as 
the correct standard and then applying a different standard.  We agree, although we attribute much of 
the confusion to Decker's arguments before the Commission.  Decker argues on appeal that the 
evidence he presented to the Commission was that he sustained an aggravation of 
his condition over a period of time.  
On the other hand, Decker's counsel argued to the 
Commission:

 
 
[N]owhere 
in the Division's disclosure statement or in the Division's final determination 
of January 22, 2002 is the issue that Wyoming Statute 27-14-603 is applicable to 
this case.  So I would simply submit 
that that is not an issue in this case at this point in 
time.

 
 
[¶38]   On appeal, Decker states that the 
Medical Commission "recognized that the position being advanced by Mr. Decker 
was that he sustained the aggravation over a substantial period of time."  Because Decker has settled on this 
position, the Commission's revised order should analyze Decker's claim under the 
heightened burden of proof required by Wyo. Stat. Ann. § 27-14-603 (LexisNexis 
2005).

 
 
[¶39]   Decker also argues on appeal that 
it "is immaterial whether he actually suffered from TOS, and if so, whether it 
was caused by his employment or was congenital."  With this we cannot agree.  Although the diagnosis attached to the 
condition may not be as important, whether the condition is congenital or was 
caused by Decker's employment is an important distinction.  If it is Decker's position, as it seems 
to be in most of his argument, that his condition is congenital, that means it 
is a preexisting condition.  A 
preexisting condition is not a compensable injury unless the injured employee 
proves that his employment materially aggravated his 
condition.  Boyce v. State ex rel. Wyoming Workers' 
Safety and Comp. Div., 2005 WY 9, ¶ 11, 105 P.3d 451, 455 (Wyo. 2005); Frontier Refining, Inc. v. Payne, 2001 
WY 49, ¶ 8, 23 P.3d 38, 40 (Wyo. 2001).

 
 
[¶40]   On remand then, the Medical 
Commission must determine whether Decker has proven that his work materially 
aggravated his congenital condition.  
To guide the Commission's determination, we reiterate our recent 
observations concerning the type of evidence required to prove a material 
aggravation.

 
 
The 
causal connection between the work and the condition is satisfied if the medical 
expert testifies it is more probable than not that the work contributed in a 
material fashion to the aggravation of the injury.  Expert medical testimony to the effect 
that the work "contributed to" the injury or that the injury "most likely" or 
"probably" is the product of the workplace suffices.  We can find no authority for the 
proposition that the medical expert must state with specificity that the work 
conditions "materially or substantially" aggravated the preexisting 
condition.  Nor can we find 
authority requiring the medical expert to apportion the aggravation between work 
conditions and other possible contributing factors.  In fact, Larson opines, except by 
exceptional statute in a few states, of which Wyoming is not one, "the relative contribution 
of the accident and the prior disease is not weighed . . . ."  

 
 
* * * * 

 
 
            
These cases make clear that our case law requiring a claimant to show his 
or her employment "materially or substantially aggravated" the preexisting 
injury does not require expert medical testimony specifically using the words 
"substantial or material."  Rather, 
what our cases require is that the claimant show that work activities, rather 
than the natural progression of the condition, factors associated with ordinary 
daily living or some other non-work related factor, significantly aggravated the 
preexisting condition.  The nexus 
between work activities and the aggravation ordinarily will be shown through 
expert opinion testimony.  That is, 
expert medical testimony ordinarily will be required to establish the link 
between the worsening of the medical condition and the claimant's work 
activities, rather than some other factor.  
The materiality of the nexus ordinarily will be shown through evidence of 
the facts and circumstances surrounding the employment.  Stated simply, the claimant is required 
to prove by a preponderance of all of the evidence that the work activities were 
a significant factor in the worsening of the preexisting 
condition.

 
 

Boyce, ¶¶ 11, 
16, 105 P.3d  at 455, 456 (citations omitted).  

 
 

Second 
Compensable Injury

 
 
[¶41]   We agree with Decker that the 
second compensable injury rule is not at issue in this matter.  Decker has not contended that bilateral 
wrist tendinitis or his wearing of a wrist splint for that originally diagnosed 
condition caused his thoracic outlet syndrome.  His argument, as presented to the 
Commission and on appeal, is that "the wrist pain presentation was nothing more 
than a symptom of the thoracic outlet syndrome."  Decker argues that the injury for which 
he filed the August 27, 2001, injury report was the thoracic outlet 
syndrome.  The Medical Commission 
must determine, after weighing the evidence, whether that is in fact the case, 
but because Decker is not claiming a new or different injury from his original 
injury, the second compensable injury rule does not apply and Decker was not 
required to file a new injury report.  

 
 
CONCLUSION

 
 
[¶42]   We hereby reverse the order of the 
district court and remand this case to the district court with directions to 
vacate the order denying benefits.  
Further, the district court is to remand the case for supplemental 
findings of fact or other proceedings consistent with this 
opinion.

 
 

FOOTNOTES

 
 

1In his 
deposition testimony, Dr. Schabauer explained that thoracic outlet syndrome and 
brachial plexus impingement are different conditions in that thoracic outlet 
syndrome involves arterial, vascular and nerve impingement, while brachial 
plexus impingement is only nerve impingement.  He also noted, though, that the terms 
are commonly used interchangeably.

 

2On 
December 4, 2003, Decker saw Dr. Anne MacGuire for an examination to evaluate 
whether he suffers from arthritis.  
Dr. MacGuire did not provide an opinion concerning what might be causing 
Decker's symptoms, but she did rule out arthritis.