TENNESSEE BUREAU OF WORKERS’ COMPENSATION

IN THE COURT OF WORKERS’ COMPENSATION CLAIMS

AT MURFREESBORO

ANDREA WILHELM, ) Docket No. 2021-05-0320

Employee, )

v. )

WALGREEN CO., ) State File No. 62588-2019

Employer, )

And )

AMERICAN ZURICH INS. CO., ) Judge Dale Tipps

Carrier. )

COMPENSATION ORDER GRANTING BENEFITS

The threshold issue in this case is whether the Court has jurisdiction to hear Ms. 

Wilhelm’s claim for medical and disability benefits. If jurisdiction is proper, the Court 

must determine whether the work accident was the primary cause of her need for kneereplacement surgery. After a March 3, 2022 compensation hearing, the Court holds that it 

has jurisdiction and Ms. Wilhelm is entitled to medical and permanent partial disability 

benefits related to her knee replacement.

History of Claim

Ms. Wilhelm fell and injured her left knee at work on August 19, 2019. Walgreen 

accepted the claim and provided medical benefits. This included treatment with Dr. 

Jonathan Petit, who diagnosed a radial tear of the posterior horn of the medial meniscal 

root and performed surgery to repair the tear in October. During the operation, Dr. Petit 

saw evidence of a previous ACL repair and grade II to grade III chondromalacia in the 

medial femoral condyle.

Ms. Wilhelm’s condition initially improved, but by April 2020, Dr. Petit concluded

the meniscal repair had failed and recommended a knee replacement. He referred her to 

Dr. Scott McCall to discuss surgical options.

By the time Ms. Wilhelm saw Dr. McCall in June, she reported severe pain that was 

FILED

Mar 16, 2022

09:10 AM(CT)

TENNESSEE COURT OF

WORKERS' COMPENSATION

CLAIMS
limiting her daily activities and ability to work. He found that her knee had degenerated to 

the point that it was now “bone on bone,” and he recommended a Stryker MAKO1total 

left-knee arthroscopy. Walgreen submitted the surgical recommendation to Utilization 

Review, which denied the MAKO procedure as not medically necessary under the 

treatment guidelines. Dr. McCall appealed the denial to the Bureau’s Medical Director,

who upheld the denial on July 27.

Ms. Wilhelm continued to treat with Dr. McCall and proceeded with the kneereplacement surgery under her health insurance. Because the surgery was unauthorized, 

Walgreen paid no temporary disability benefits.2 Ms. Wilhelm reached maximum medical 

improvement on October 16, 2020, and returned to full-duty work at a higher wage than 

she was earning at the time of her injury.

In his deposition, Dr. McCall identified the work injury as the primary cause of Ms. 

Wilhelm’s need for knee replacement. He explained that a tear of the meniscal root is

problematic because it tends to allow the meniscus to sublux out of the joint, which he 

characterized as essentially “a full, complete meniscectomy.” He went on: “You have no 

intact fibers. That transfers all of the patient’s weight onto the articular cartilage of the 

knee . . . which causes rapid progression of arthritis.” 

Dr. McCall said that this is what happened to Ms. Wilhelm. Her post-surgery MRI 

on February 22 showed eighty-percent extrusion of the meniscus. This meant that the 

repair had failed, resulting in a rapid progression of arthritis. He testified that, without the 

root tear, she would not have needed the knee replacement at that time. Dr. McCall also 

explained that the scans, as well as what he observed during surgery, showed a progression 

from mild chondromalacia to bone-on-bone in about six months. He added that this was 

common, and he had seen similar degeneration in as little as three months after an 

attempted root repair.

For these reasons, and because Ms. Wilhelm’s knee was functioning with no 

problems before August 2019, Dr. McCall said the work injury was the primary cause of 

her need for knee replacement. As for impairment, he assigned a rating of ten percent. 

When asked about the impairment rating for just the meniscal repair surgery, Dr. McCall 

stated it would have been three percent.

On cross-examination, Dr. McCall acknowledged that Ms. Wilhelm had ACL 

reconstruction surgery for her left knee in 1998, but he said that it had not resulted in posttraumatic arthritis. He stated, “If she was going to get post-traumatic arthritis from the 

ACL, that would have already happened.”

1

“Stryker MAKO” refers to a robot-assisted surgical procedure.

2 The parties stipulated that Ms. Wilhelm received short-term disability benefits through a Walgreen-funded 

program.
Dr. McCall was also shown a Physician Certification Form he signed in February 

2021 certifying that Ms. Wilhelm no longer had the ability to perform her pre-injury 

occupation. He did not remember signing the form or why he did. He suggested he might 

have misread the form or made a mistake.

At Walgreen’s request, Dr. William Gavigan performed a records review and gave 

a deposition. He agreed that knee-replacement surgery was a reasonable option to treat 

Ms. Wilhelm’s arthritis. However, he said the need for knee replacement was “more than 

fifty percent probability caused by the ongoing arthritis.” He felt that arthritis was a 

degenerative condition from the old ACL injury because “the torn meniscus would not 

result in the joint space narrowing that quickly.” Although he conceded that the meniscus 

injury accelerated her condition, he maintained that the pre-existing arthritis was the 

primary cause of her need for knee replacement.

Ms. Wilhelm testified that she had no problems or pain with her knee after she 

recovered from the 1998 ACL repair. Her job required her to stand and walk about seven 

or eight hours a day, and until this injury, she was able to do her work without any problems

or knee pain. Further, her knee did not affect her other daily activities.

Ms. Wilhelm asked the Court to award permanent partial disability benefits based 

on Dr. McCall’s ten-percent impairment rating. She also asked that Walgreen pay the 

medical bills from her knee replacement.

Walgreen contended that the Court does not have jurisdiction over the knee 

replacement issue because she did not exhaust her administrative remedies before filing 

her Petition for Benefit Determination. Alternatively, it argued her claim is barred because 

her petition was not timely filed. Walgreen further claimed that Ms. Wilhelm is not entitled 

to any benefits related to her knee replacement because the need for that procedure was not

primarily caused by her work injury.

Findings of Fact and Conclusions of Law

Ms. Wilhelm, as the employee in a workers’ compensation claim, has the burden of 

proof on all essential elements of her claim. Scott v. Integrity Staffing Solutions, 2015 TN 

Wrk. Comp. App. Bd. LEXIS 24, at *6 (Aug. 18, 2015). At a compensation hearing, she 

must show by a preponderance of the evidence that she is entitled to the requested benefits. 

Willis v. All Staff, 2015 TN Wrk. Comp. App. Bd. LEXIS 42, at *18 (Nov. 9, 2015). 

Jurisdiction

Walgreen first argued that Ms. Wilhelm’s claim must be denied because she did not 

comply with timing provisions in the Bureau’s Utilization Review regulations. 
Specifically, it argued that she failed to timely file a petition after the Medical Director

upheld denial of the knee replacement. 

Tennessee Compilation Rules and Regulations 0800-02-06-.07(6) (January, 2017) 

provides that any party disagreeing with the Medical Director’s decision “may file a 

Petition for Benefit Determination (PBD) with the Court of Workers’ Compensation 

Claims within seven business days of the receipt of the determination.” Because the 

Medical Director issued his decision in this case on July 27, 2020, and Ms. Wilhelm did 

not file her petition until April 7, 2021, Walgreen contended she has no right to now contest 

the denial. The Court disagrees for several reasons.

First, although Walgreen introduced a copy of the Medical Director’s letter into 

evidence, Ms. Wilhelm testified that she never received it. Walgreen offered no evidence

to the contrary, including no proof as to when, how, or even if the letter was mailed. The 

Court found Ms. Wilhelm to be a credible witness throughout the hearing and accepts this 

testimony. Similarly, the parties submitted no evidence as to when Ms. Wilhelm first saw 

the letter. Thus, the unrebutted proof is insufficient to determine when or if she received

the Medical Director’s decision. Under the explicit text of Rule 0800-02-06-.07(6), this 

means the Court cannot find that the seven-day period was ever triggered.

Further, even if Ms. Wilhelm had received the denial notice, the effect of Rule 0800-

02-06-.07(6) is not what Walgreen argued. The rules do not suggest that the seven-day 

period operates to limit injured employees’ access to the Court. Rather, other subsections 

explain the consequence of missing the seven-day window. Rules 0800-02-06-.06(7)(a)

and 0800-02-06-.07(5) state that the Medical Director’s denial “shall remain effective for 

a period of 6 months from the date of the decision” unless there is “material change 

documented by the treating physician that supports a new review or other information that 

was not used by the [reviewing physician] in making the initial decision.” In other words,

the Medical Director’s denials are not permanent. If Ms. Wilhelm had received the denial 

and failed to file a petition within seven business days, the only effect in the rules would 

have been a six-month waiting period before she could resubmit the surgical request to 

Utilization Review. The rules do not preclude her filing a petition after the expiration of 

that period.

Walgreen also argued that Ms. Wilhelm’s failure to file the petition within seven 

days means that the Court has no jurisdiction over this claim because she failed to exhaust 

her administrative remedies.

3

 It cited Tristar Centennial Med. Ctr. v. Pugh, No. M2016-

02470-SC-R3-WC, 2018 Tenn. LEXIS 63 (Tenn. Workers’ Comp. Panel Feb. 15, 2018), for 

the proposition that “where a statute provides an administrative remedy, such remedy must 

3 Walgreen argued in the alternative that Ms. Wilhelm failed to exhaust her administrative remedies because 

she failed to appeal the Medical Director’s decision. This argument is without merit because, other than 

filing a petition, the rules provide no other “appeal” or method of challenging the Medical Director’s 

decision.
first be exhausted before the courts will act.” This is an accurate statement of law, but 

Walgreen urged the Court to overlook the fact that Tristar was decided under prior law. 

The Court cannot do this.

The Supreme Court has held that, “[U]nless the statute providing for an 

administrative remedy requires exhaustion [of remedies] ‘by its plain words,’ an 

administrative appeal is not mandatory[.] Absent a statutory mandate, the exhaustion of 

the administrative remedies doctrine is a matter of judicial discretion.” Thomas v. State 

Bd. of Equalization, 940 S.W.2d 563, 566 n.5 (Tenn. 1997). 

Tennessee Code Annotated section 50-6-124 empowers the Bureau to establish a 

utilization review program. Nothing in the current version of that section or the resulting 

rules requires an employee to exhaust administrative remedies before filing a petition 

seeking benefits after a Utilization Review denial. In fact, the administrative procedure of 

filing a petition to challenge the Medical Director’s denial is couched in permissive (a party 

“may file”), not mandatory, terms. Nothing in the plain words of the Workers’ 

Compensation Law or the Utilization Review regulations mandates that the only way to 

challenge the Medical Director’s denial of treatment is to file a petition within seven 

business days of that denial. At most, it might be argued that a Court is constrained from 

acting on the issue until the six-month period expires. However, once six months have 

passed, as here, even that argument is untenable. In this situation, the Court can consider 

remedies sought by a party who disagrees with the Medical Director’s decision. Therefore, 

Walgreen’s jurisdiction argument is without merit.

Causation

Ms. Wilhelm must show that her injuries arose primarily out of and in the course 

and scope of her employment. See Tenn. Code Ann. § 50-6-102(14)(A). Neither of the

physicians disputed Ms. Wilhelm’s need for knee-replacement surgery.

4

 Instead, they 

disagreed on whether that need was primarily caused by her work injury.

A trial court generally has the discretion to choose which expert to accredit when 

there is a conflict of expert opinions. Brees v. Escape Day Spa & Salon, 2015 TN Wrk. 

Comp. App. Bd. LEXIS 5, at *14 (Mar. 12, 2015). In evaluating conflicting expert 

testimony, a trial court may consider, among other things, “the qualifications of the experts, 

the circumstances of their examination, the information available to them, and the 

evaluation of the importance of that information through other experts.” Id. 

Although Dr. McCall is the authorized treating physician, his causation opinion is 

not afforded a presumption of correctness because he was not selected from a panel of 

4 Neither, apparently, did the Utilization Review physician. Instead, it appears the only reason the surgery 

was not approved was the proposed use of the MAKO robot.
physicians. See Gilbert v. United Parcel Serv., Inc., 2019 TN Wrk. Comp. App. Bd. LEXIS 

20, at *13 (June 7, 2019). However, after reviewing the doctors’ testimony and considering 

the other factors set out in Brees, the Court finds Dr. McCall’s opinion to be more 

persuasive. He not only treated Ms. Wilhelm, but also he performed the surgery and 

personally observed the interior condition of her knee. 

Case law generally supports this conclusion. “It seems reasonable that the physicians 

having greater contact with the Plaintiff would have the advantage and opportunity to provide 

a more in-depth opinion, if not a more accurate one.” Orman v. Williams Sonoma, Inc., 803 

S.W.2d 672, 677 (Tenn. 1991); see also Smith v. TrustPoint Hosp., LLC, 2021 TN Wrk. 

Comp. App. Bd. LEXIS 1, at *21 (Jan. 6, 2021) (trial court did not err in accepting the 

authorized treating physician’s opinion over that of another expert, where the authorized 

physician had the benefit of seeing the employee’s condition during surgery, which 

confirmed his pre-operative diagnoses, and where the authorized physician “followed 

Employee as a patient and saw her lack of progress with conservative care firsthand.”)

Dr. Gavigan, on the other hand, performed a record review. He never examined Ms. 

Wilhelm or spoke with her about her injury or the onset and progression of her symptoms. 

He was unfamiliar with the procedure used in her surgery, and no evidence showed that he

personally looked at any of her x-ray or MRI films.

These differences matter because the central dispute between the doctors is the

extent to which Ms. Wilhelm’s pre-existing arthritis caused the need for her knee 

replacement. Dr. Gavigan focused on the chondromalacia observed by Dr. Petit, which

was not caused by the work injury. Then, a few months after the meniscus surgery, the xrays showed a loss of joint space, which Dr. Gavigan agreed was a new finding. Less than 

a month later, the joint space was completely collapsed. He characterized this as “advanced 

arthritis” justifying a knee replacement, but he concluded that the primary cause of the need 

for knee replacement was the ongoing arthritis. The basis for this opinion was, “I believe 

the torn meniscus would not result in the joint space narrowing that quickly.” 

Dr. McCall, on the other hand, provided a detailed explanation of how meniscal root 

tears commonly cause this rapid progression of arthritis and said he had observed similar 

degeneration in as little as three months after an attempted root repair. While he 

acknowledged Ms. Wilhelm might have needed a knee replacement later in life, she would 

not have needed it at this time, were it not for the work injury.

Walgreen contended that Dr. McCall’s execution of the Physician Certification 

Form, after Ms. Wilhelm had already returned to work, suggested that his testimony was 

too biased to be reliable. The Court disagrees. The doctor could not recall why he had 

signed the form and believed he did so by mistake. Without more, this is insufficient to 

disregard Dr. McCall’s thorough explanation of the mechanism of injury or to question the 

veracity of his testimony. Further, his conclusion about the rapid decline of Ms. Wilhelm’s 
knee condition is supported by her unrefuted testimony that until this injury, she was able 

to do her work without any problems or knee pain.5 

Finally, Walgreen objected to what it perceives as a return to the liberal construction 

of the statute in Utilization Review disputes, based ostensibly on the treating physician’s 

presumption of correctness.6 As applied to this case, this argument improperly conflates 

the issues of causation and medical necessity, and it is unpersuasive on both counts. 

Walgreen’s argument is inapplicable to the issue of causation in this case, because, as noted 

above, Dr. McCall’s opinion is not entitled to that presumption. Instead, his opinion was 

simply more persuasive than Dr. Gavigan’s, and Utilization Review does not address 

causation questions.

On the other hand, Dr. McCall is presumed to be correct on the question of medical 

necessity and reasonableness. See Tennessee Code Annotated section 50-6-204(a)(3)(H). 

However, this was not an issue for the hearing, as all the doctors agreed knee replacement

was necessary and reasonable. To the extent the necessity of the MAKO procedure was 

called into question, that issue expired at the end of the six-month period in the rules. 

Further, as Walgreen offered no evidence regarding the Utilization Review physician’s 

interpretation of the treatment guidelines, the proof would have been insufficient to 

overcome the presumption.

For these reasons, the Court finds that Ms. Wilhelm met her burden of proving by a 

preponderance of the evidence that her need for knee replacement was primarily caused by 

the August 19, 2019 work injury.

Permanent Disability

Because Ms. Wilhelm’s knee replacement is compensable, she is entitled to receive 

5 While causation of an injury must be shown by expert medical testimony, medical proof “must be 

considered in conjunction with the lay testimony of the employee as to how the injury occurred and the 

employee's subsequent condition.” Thomas v. Aetna Life & Cas. Co., 2015 TN Wrk Comp App Bd LEXIS 

15, at *9 (May 27, 2015).

6 Walgreen asked, “What’s the employer supposed to do? Is it supposed to pay just because the ATP 

recommended it?” It maintained it chose not to pay for this procedure “because it was told it didn’t have 

to. . . We have rules, and we should follow those rules.” The Appeals Board addressed this question in 

Walls v. United Technologies Corp., 2021 TN Wrk Comp App Bd LEXIS 27, at *22, 23 (Aug. 6, 2021). 

“Nothing in the statute relieves an employer of its burden of proof or the consequences of its decision to 

deny medical treatment merely because it sought utilization review of the prescribed treatment, then relied 

on the reviewing physician’s ‘decertification’ recommendation. The utilization review provider does not 

deny an employee's request for medical treatment, nor does the Bureau's Medical Director. Ultimately, the 

decision to approve or deny medical treatment recommended by an authorized physician rests with the 

employer and, perhaps, its insurer. An employer can choose to authorize treatment even if its utilization 

review physician recommends ‘decertification.’ See Tenn. Comp. R. & Regs. 0800-02-06-.06(6)(a) . . . [I]t 

is the employer that must accept the consequences of its decision to deny such treatment if that decision 

turns out to be ‘erroneous, incorrect, or otherwise inconsistent with the law or facts.’”
permanent partial disability benefits for that condition. See Tenn. Code Ann. § 50-6-

207(3)(A).

Dr. McCall testified that the rating for Ms. Wilhelm’s knee replacement under the 

AMA Guides, 6

th edition is ten percent to the body. This equals forty-five weeks of

permanent partial disability benefits at the stipulated compensation rate of $921.83, or 

$40,560.52. The parties agreed that Walgreen was entitled to a set-off of $1,475.87, based 

on an overpayment of employer-funded short-term disability paid instead of temporary 

disability benefits. Thus, her permanent partial disability award is $39,084.65.

Medical Benefits

 

The Workers’ Compensation Law requires an employer to provide reasonable, 

necessary treatment at no cost to the injured worker. Tenn. Code Ann. § 50-6-204. The parties 

stipulated that, if the Court found the knee replacement compensable, Walgreen would be 

responsible for satisfying any outstanding claims for payment, subrogation, or 

reimbursement of the related medical expenses. Therefore, Walgreen shall provide future 

medical benefits with Dr. McCall and shall pay Ms. Wilhelm’s medical providers and

health insurer under the fee schedule. It shall also reimburse Ms. Wilhelm for her out-ofpocket payments.

IT IS, THEREFORE, ORDERED as follows:

1. Walgreen shall provide reasonable and necessary future medical benefits with 

Dr. McCall for Ms. Wilhelm’s left-knee work injury.

2. Walgreen shall reimburse the health insurer under the fee schedule for payments 

to Dr. McCall, the surgery center, physical therapy, and any other providers for

her knee-replacement surgery.

3. Walgreen shall reimburse Ms. Wilhelm for her out-of-pocket payments from her 

knee-replacement surgery.

4. Walgreen shall pay Ms. Wilhelm permanent partial disability benefits of 

$39,084.65.

5. Ms. Wilhem’s attorney is entitled to a twenty-percent fee from this award under 

Tennessee Code Annotated section 50-6-226(a)(1), or $8,112.10. Ms. 

Wilhelm’s attorney may file a motion for discretionary costs and an affidavit 

under Rule 54 of the Tennessee Rules of Civil Procedure within seven days of 

the date of this Order.

6. The Court taxes the $150.00 filing fee to Walgreen, to be paid to the Court Clerk 
under Tennessee Compilation Rules and Regulations 0800-02-21-.06 (February, 

2022) within five business days of this order becoming final, and for which 

execution might issue if necessary.

7. Walgreen shall file a Statistical Data Form (SD-2) with the Court Clerk within 

five business days of the date this order becomes final.

8. Unless appealed, this order shall become final thirty days after entry.

ENTERED March 16, 2022.

_________________________

Judge Dale Tipps

Court of Workers’ Compensation Claims

APPENDIX

Exhibits:

1. Transcript of Dr. William Gavigan’s deposition

2. Transcript of Dr. Scott McCall’s deposition

3. Medical Director’s letter of July 27, 2020

4. June 10, 2020 Utilization Review report of Dr. Steven Arsht

5. Ms. Wilhelm’s responses to Walgreen’s Requests for Admissions

Technical record:

1. Petition for Benefit Determination 

2. Dispute Certification Notice

3. Request for Expedited Hearing

4. Scheduling Order

5. Employer’s Pre-Hearing Brief

6. Employee’s Pre-Hearing Brief

7. Joint Pre-Compensation Hearing Statement

8. Employer’s Witness and Exhibit List

9. Employee’s Witness and Exhibit List
CERTIFICATE OF SERVICE

I certify that a copy of this Compensation Order was sent as indicated on March 16, 

2022.

Name Certified 

Mail

Email Service Sent To

Jill T. Draughon,

Employee’s Attorney

X jdraughon@hughesandcoleman.com

John R. Lewis,

Employer’s Attorney

X john@johnlewisattorney.com

_____________________________________

Penny Shrum, Clerk

Court of Workers’ Compensation Claims

WC.CourtClerk@tn.gov
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.

Compensation Hearing Order Right to Appeal:

If you disagree with this Compensation Hearing Order, you may appeal to the Workers’ 

Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers’ 

Compensation Appeals Board, you must:

1. Complete the enclosed form entitled: “Notice of Appeal,” and file the form with the 

Clerk of the Court of Workers’ Compensation Claims within thirty calendar days of the 

date the compensation hearing order was filed. When filing the Notice of Appeal, you 

must serve a copy upon the opposing party (or attorney, if represented). 

2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten 

calendar days after filing of the Notice of Appeal. Payments can be made in-person at 

any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the 

alternative, you may file an Affidavit of Indigency (form available on the Bureau’s 

website or any Bureau office) seeking a waiver of the filing fee. You must file the fullycompleted Affidavit of Indigency within ten calendar days of filing the Notice of 

Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will 

result in dismissal of your appeal.

3. You bear the responsibility of ensuring a complete record on appeal. You may request 

from the court clerk the audio recording of the hearing for a $25.00 fee. A licensed court 

reporter must prepare a transcript and file it with the court clerk within fifteen calendar 

days of the filing the Notice of Appeal. Alternatively, you may file a statement of the 

evidence prepared jointly by both parties within fifteen calendar days of the filing of the 

Notice of Appeal. The statement of the evidence must convey a complete and accurate 

account of the hearing. The Workers’ Compensation Judge must approve the statement 

of the evidence before the record is submitted to the Appeals Board. If the Appeals 

Board is called upon to review testimony or other proof concerning factual matters, the 

absence of a transcript or statement of the evidence can be a significant obstacle to 

meaningful appellate review.

4. After the Workers’ Compensation Judge approves the record and the court clerk transmits 

it to the Appeals Board, a docketing notice will be sent to the parties. The appealing 

party has fifteen calendar days after the date of that notice to submit a brief to the 

Appeals Board. See the Practices and Procedures of the Workers’ Compensation 

Appeals Board. 

To appeal your case directly to the Tennessee Supreme Court, the Compensation Hearing 

Order must be final and you must comply with the Tennessee Rules of Appellate 

Procedure. If neither party timely files an appeal with the Appeals Board, the trial court’s 

Order will become final by operation of law thirty calendar days after entry. See Tenn. 

Code Ann. § 50-6-239(c)(7).
LB-1099 rev. 01/20 Page 1 of 2 RDA 11082 

NOTICE OF APPEAL 

Tennessee Bureau of Workers’ Compensation

www.tn.gov/workforce/injuries-at-work/ 

wc.courtclerk@tn.gov | 1-800-332-2667 

Docket No.: ________________________

State File No.: ______________________ 

Date of Injury: _____________________ 

___________________________________________________________________________ 

Employee

v.

___________________________________________________________________________ 

Employer

Notice is given that ____________________________________________________________________ 

[List name(s) of all appealing party(ies). Use separate sheet if necessary.]

appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the 

Workers’ Compensation Appeals Board (check one or more applicable boxes and include the date filestamped on the first page of the order(s) being appealed):

□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________

□ Compensation Order filed on__________________ □ Other Order filed on_____________________

issued by Judge _________________________________________________________________________. 

Statement of the Issues on Appeal 

Provide a short and plain statement of the issues on appeal or basis for relief on appeal: 

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Parties

Appellant(s) (Requesting Party): _________________________________________ ☐Employer ☐Employee 

Address: ________________________________________________________ Phone: ___________________ 

Email: __________________________________________________________ 

Attorney’s Name: ______________________________________________ BPR#: _______________________ 

Attorney’s Email: ______________________________________________ Phone: _______________________ 

Attorney’s Address: _________________________________________________________________________ 

* Attach an additional sheet for each additional Appellant *
LB-1099 rev. 01/20 Page 2 of 2 RDA 11082 

Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________ 

Appellee(s) (Opposing Party): ___________________________________________ ☐Employer ☐Employee 

Appellee’s Address: ______________________________________________ Phone: ____________________ 

Email: _________________________________________________________ 

Attorney’s Name: _____________________________________________ BPR#: ________________________ 

Attorney’s Email: _____________________________________________ Phone: _______________________ 

Attorney’s Address: _________________________________________________________________________ 

* Attach an additional sheet for each additional Appellee *

CERTIFICATE OF SERVICE 

I, _____________________________________________________________, certify that I have forwarded a 

true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described 

in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this 

case on this the __________ day of ___________________________________, 20 ____. 

 ______________________________________________ 

[Signature of appellant or attorney for appellant]