1 

ARKANSAS COURT OF APPEALS

DIVISION I 

No. CV-13-310 

ROSE BUTLER

APPELLANT

V.

LAKE HAMILTON SCHOOL 

DISTRICT, RISK MANAGEMENT 

RESOURCES, and ARKANSAS 

SCHOOL BOARDS ASSOCIATION 

DEATH & PERMANENT TOTAL 

DISABILITY TRUST FUND

APPELLEES

Opinion Delivered December 4, 2013

APPEAL FROM THE ARKANSAS 

WORKERS’ COMPENSATION 

COMMISSION

[NO. F800967]

AFFIRMED ON DIRECT APPEAL; 

AFFIRMED ON CROSS-APPEAL

BRANDON J. HARRISON, Judge

 Rose Butler appeals from the Workers’ Compensation Commission’s decision to 

deny her certain benefits. She argues that the Commission mistakenly found that she had 

reached the end of her healing period in July 2009 and was therefore not entitled to 

receive temporary-total-disability benefits. She also believes the Commission wrongly 

concluded that she was not entitled to treat with Drs. Bodemann, Burba, Ackerman, and 

Hefley. 

The Lake Hamilton School District, Risk Management Resources, and Arkansas 

School Boards Association Death & Permanent Total Disability Trust Fund have crossappealed. The issue on cross-appeal is whether the Commission erred in awarding Butler 

medical treatment from Drs. Pellegrino and Archer. 

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I. Temporary-Total-Disability Benefits

For more than eight years, Rose Butler worked for the Lake Hamilton School 

District preparing school lunches for children. The parties stipulated that, in November 

2007, Butler sustained a compensable injury to her left shoulder, arm, and hand when she 

tripped while reaching for the microwave in the school kitchen. Butler, who was near 

seventy years old when injured, received a shoulder surgery in February 2008, wrist 

surgery in September 2008, and a second shoulder surgery in December 2008. The 

School District’s insurance carrier authorized these surgeries as treatment for Butler’s 

compensable work injury. Dr. Michael Young performed the surgeries. 

Butler continued to have problems with the left side of her upper body, and the 

carrier allowed her to see Dr. Annette Meador in March 2009 for more treatment. Dr. 

Meador recommended a series of stellate ganglion blocks and a MRI. In early June 

Meador noted that Butler had “reflex sympathetic dystrophy” in her left upper extremity, 

but that “overall she is better than prior to her first evaluation [in March].” Dr. Meador 

soon released Butler from her care, noting “I believe she [Butler] has reached maximum 

improvement and is no further in need of any stellate ganglion blocks.” She also 

recommended that Butler receive a functional-capacity evaluation and a permanency 

rating from Dr. Young. 

Butler participated in a functional-capacity evaluation in late June; its results were 

deemed unreliable for various reasons. 

Butler testified at the hearing before the administrative law judge that tremors in 

her left arm began the day of the functional-capacity evaluation and that she was in 

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tremendous pain during the exam. Dr. Young, however, agreed with Dr. Meador that 

Butler had reached her maximum medical improvement by July 2009. Dr. Young 

specifically wrote that Butler had “reached her maximum medical improvement. I do not 

think further surgery is warranted at this point.” He then gave Butler a twelve percent 

permanent-impairment rating and recommended that she be off permanently from her 

job. After follow up visits in September 2009 and January 2010, Dr. Young referred 

Butler to two neurologists to assess the tremors in her left arm. 

In July 2009, the carrier stopped paying for additional treatment. Thereafter, on 

her own initiative, Butler visited several unauthorized doctors about the tremors. One of 

those doctors, neurologist Dr. Alonzo Burba, ordered a MRI in 2010. The test showed 

“no dominant enhancing mass lesion or abnormality involving the left axilla or left 

brachial plexus.” Dr. William Akerman—another unauthorized doctor—wrote in April 

2011 that “it is my medical opinion that this patient is not at maximum medical 

improvement.” He cited Butler’s complex regional pain syndrome, injury to her left 

shoulder and rotator cuff, trapezius muscle spasms, and pain in her right knee as evidence 

that her healing period had not yet ended. 

The administrative law judge found that Butler proved that she was entitled to 

additional total-temporary-disability benefits until a date yet to be determined. That 

decision was challenged, and the Commission reversed. It found that Butler had not 

proven that she was entitled to total-temporary-disability benefits after July 2009. The 

Commission weighed the medical evidence and found that Butler had reached the end of 

her healing period no later than 20 July 2009, that the left-arm tremors did not extend her 

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healing period, and that she did not re-enter a healing period. The Commission relied on 

Dr. Young’s and Dr. Meador’s opinions to conclude that Butler’s healing period had 

ended in July 2009. Butler contests the Commission’s decision.

When an injured employee is totally incapacitated from earning wages and remains 

within her healing period, she is entitled to temporary total disability. Riggs v. B & S 

Contractors, Inc., 2010 Ark. App. 554, 377 S.W.3d 466. The healing period continues 

until the employee is restored as much as the permanent character of her injury will 

permit. Id. It ends when the underlying condition causing the disability becomes stable 

and no treatment will improve it. Id. When the healing period has ended is a fact-based 

question that the Commission must answer. Id. We review the Commission’s decision in 

the light most favorable to its findings and affirm when the decision is supported by 

substantial evidence. Parker v. Atl. Research Corp., 87 Ark. App. 145, 151, 189 S.W.3d 

449, 452–53 (2004). Substantial evidence is evidence that a reasonable mind might accept 

as adequate to support a conclusion. Id. 

Here, substantial evidence supports the Commission’s decision on temporary-totaldisability benefits. Butler received three surgeries and other treatments to repair the 

workplace injuries. Her surgeon (Young) and another specialist (Meador) specifically 

stated that Butler had reached maximum medical improvement by July 2009. The 

Commission placed “significant evidentiary weight” on the 2010 MRI, which showed no 

gross abnormalities with Butler’s brachial plexus. The Commission was entitled to weigh 

all the evidence and credit the medical opinions of Drs. Young and Meador over Dr. 

Akerman’s contrary opinion on the healing-period issue. See SSI, Inc. v. Cates, 2009 Ark. 

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App. 763, 350 S.W.3d 421. We will not reverse the Commission’s decision regarding 

which medical evidence it chooses to accept when the medical evidence is conflicting, as 

it is in this case. Id. The Commission may not arbitrarily disregard medical evidence or 

the testimony of any witness, id., but we do not find that the Commission arbitrarily 

disregarded particular medical evidence. 

We therefore affirm the Commission’s decision that Butler did not prove that she 

was entitled to temporary-total-disability benefits after her healing period ended in July 

2009. 

II. Unauthorized Physicians 

Approximately eight months after the carrier had controverted any additional 

medical treatment, Butler saw her family physician, Dr. Michael Bodemann, who sent her 

to Dr. Lon Burba, a neurologist. Dr. Burba ordered tests, evaluated Butler, and eventually 

sent her to Dr. William Akerman for pain management. Dr. Akerman in turn 

recommended that Butler see Dr. Kevin Collins for a rehabilitation evaluation. Dr. 

William Hefley, Jr. also assessed Butler and recommended that she continue to see Dr. 

Burba, so he could oversee the management of her reflex sympathetic dystrophy (RSD).

Dr. Hefley also wrote, “I would not want to operate now as it might exacerbate her RSD.

I think her predominant pain source is the RSD.” 

The Commission ruled that the appellees did not have to pay for Butler’s treatment 

with Drs. Bodemann, Burba, Ackerman, and Hefley because they were unauthorized 

physicians. The record shows that Butler did not petition the Commission for a changeof-physician pursuant to Ark. Code Ann. § 11-9-514(b); nor did she follow the statute’s 

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provisions that allow medical treatment to be authorized if certain steps are followed after 

the carrier controverts treatment. Ark. Code Ann. § 11-9-514(f). And Butler signed an 

AR-N notice document informing her that any unauthorized medical expenses were her 

sole responsibility. We therefore affirm the Commission’s decision that the appellees do 

not have to pay for visits to Drs. Bodemann, Burba, Ackerman, and Hefley. Nor do the 

appellees have to pay for any referrals that these four doctors made. 

III. The Cross-Appeal: Additional Medical Treatment with Drs. Pellegrino & Archer 

 The Lake Hamilton School District, Risk Management Resources, and Arkansas 

School Boards Association Death & Permanent Total Disability Trust Fund have crossappealed, arguing that the Commission erred in awarding Butler evaluations from Dr. 

Pellegrino and Dr. Archer. We disagree. 

As stated earlier, one of Butler’s treating physicians, Dr. Young, wanted Butler to 

get a neurological consult regarding her left-side tremors. So Dr. Young referred Butler 

to neurologist Dr. Pellegrino, writing that “I think this is simply necessary to follow 

through with her care and try to determine where she is at this point in time.” In his 

letter to Dr. Pellegrino, Dr. Young wrote that an “essential tremor appears to be in 

[Butler’s] upper extremity.” The office report from the same day states, “Today on exam 

[Butler] has developed a tremor in her left upper extremity. We discussed it and I think it 

is important to get her scheduled to see a neurologist. . . . We will get her in to see Dr. 

Pellegrino.” 

The carrier did not authorize Butler to see Dr. Pellegrino. 

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At a follow-up appointment with Butler in January 2010, Dr. Young again wrote, 

“she has developed a pretty significant tremor in this left arm.” He then tried to refer 

Butler to a neurologist at UAMS, Dr. Lee Archer, to get his advice after the carrier 

refused to let her see Dr. Pellegrino. Butler never obtained a neurological evaluation from 

Dr. Pellegrino or Dr. Archer. She did receive a neurological evaluation from Dr. Burba, 

an unauthorized physician. 

The Commission found that Butler “has proven by a preponderance of the 

evidence that she is entitled to additional medical benefits.” It also wrote that Butler 

“proved she was entitled to an evaluation by Dr. Pellegrino and Dr. Archer” and that an 

“assessment of [Butler’s] tremors by Dr. Pellegrino and Dr. Archer is reasonably necessary 

management of [her] injury.” The cross-appellants take issue with this particular 

determination. 

Arkansas Code Annotated section 11-9-508(a) states that “the employer shall 

promptly provide for an injured employee such medical treatment as may be reasonably 

necessary in connection with the injury received by the employee.” An employee may 

receive ongoing medical treatment after the healing period has ended if the treatment is 

geared toward managing the compensable injury. Wilkerson v. St. Edward Mercy Med. Ctr., 

2013 Ark. App. 345, at 3. But the employee must prove by a preponderance of the 

evidence that medical treatment is reasonable and necessary. Id. What constitutes 

reasonable and necessary medical treatment is a question of fact that the Commission 

determines. Id. When the primary injury arises out of and in the course of the 

employment, the employer is responsible for any natural consequence that flows from that 

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injury. Jeter v. B.R. McGinty Mech., 62 Ark. App. 53, 58, 968 S.W.2d 645, 649 (1998). 

The basic test is whether a causal connection exists between the two episodes. Id. When 

the Commission awards a claimant benefits we will affirm the decision unless fair-minded 

persons, presented with the same facts, could not have arrived at the Commission’s

conclusion. Olsten Kimberly Quality Care v. Pettey, 328 Ark. 381, 385, 944 S.W.2d 524, 

526 (1997). 

Here, the Commission found that allowing Butler’s tremors to be assessed by Drs. 

Pellegrino and Archer was reasonably necessary for the management of her original injury: 

Whether the claimant’s complaints of tremor are truly connected to 

the compensable injury or are feigned and nonorganic, Dr. Young 

attempted to refer the claimant to Dr. Pellegrino, a neurologist, to assess the 

claimant’s left arm. The respondents did not approve treatment with Dr. 

Pellegrino. Dr. Young also attempted to refer the claimant to Dr. Archer at 

UAMS to examine the claimant’s reported tremors, but the record does not 

indicate that the respondents allowed the claimant to see Dr. Archer. The 

Full Commission therefore finds that the claimant proved she was entitled to 

an evaluation by Dr. Pellegrino and Dr. Archer. 

Cross-appellants argue that the Commission’s decision to allow an additional 

assessment regarding Butler’s left-sided tremors is not supported by substantial evidence 

because no objective findings “support a diagnosis regarding [Butler’s] ‘tremor’ 

complaints.” They also argue that no substantial proof connects Butler’s tremors to her 

compensable injury. 

There is no requirement that objective evidence, or a doctor’s opinion, is required 

before the Commission may determine that further medical treatment in connection with 

a work injury is reasonably necessary. See Evans v. Bemis Co., Inc., 2010 Ark. App. 65, 6–

7, 374 S.W.3d 51, 55 (2010). The cases that cross-appellants cite for this proposition—

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Liaromatis v. Baxter Cnty. Reg’l Hosp., 95 Ark. App. 296, 236 S.W.3d 525 (2006) and 

Smith-Blair, Inc. v. Jones, 77 Ark. App. 273, 72 S.W.3d 560 (2002)—do not require us to 

reverse. Those cases addressed aggravations of preexisting conditions and whether the 

aggravations were separate compensable injuries. Here, the Commission did not rule that 

Butler’s tremors were an aggravation of a preexisting condition or a new and separate 

compensable injury; so the objective-findings requirement at issue in Liaromatis and SmithBlair, Inc. does not apply in this case. 

We also disagree with cross-appellants’ argument that insufficient proof connects 

Butler’s tremors to her work injury. Whether a causal connection exists between an initial 

work-related injury and later problems is a question of fact that the Commission must 

resolve. Jeter, supra. This record supports the Commission’s decision. As Butler points 

out, the cross-appellants pass over Dr. Young’s 2009 note: “Today on exam she has 

developed a tremor in her upper left extremity. We discussed it and I think it is important 

to get her in to see [neurologist] Dr. Pellegrino.” Dr. Young also wrote that Butler 

thought she had sustained permanent nerve damage to her upper extremity, and that 

having Dr. Pellegrino review her situation “is simply necessary to follow through with her 

care and try to determine where she is at this point in time.” Butler had ongoing 

problems after she fell at work, and her treating physician recommended more evaluations. 

See Patchell v. Wal-Mart Stores, Inc., 86 Ark. App. 230, 236, 184 S.W.3d 31, 35 (2004) (a 

claimant may be entitled to ongoing medical treatment after the healing period has ended 

if the treatment’s purpose is to manage the compensable injury). 

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We hold that substantial evidence supports the Commission’s decision to award 

Butler evaluations from Drs. Pellegrino and Archer. 

We end with the contention that the Commission-ordered evaluations by Drs. 

Pellegrino and Archer are not reasonable or necessary medical treatment of Butler’s 

compensable injury because the same types of evaluations and testing have already been 

done by the unauthorized doctors, including the neurologist Dr. Burba. This argument 

appeals to economic efficiency, but the cross-appellants do not cite any legal authority to 

support the contention. 

IV. Conclusion 

We affirm the Commission on direct appeal and cross-appeal. 

Affirmed. 

GRUBER and WHITEAKER, JJ., agree. 

Philip M. Wilson, for appellant. 

Friday, Eldredge & Clark, LLP, by: Guy Alton Wade and Travis J. Fowler, for 

appellees. 

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