United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

C.L., Appellant 

and 

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS HEALTH ADMINISTRATION, 

New Orleans, LA, Employer 

__________________________________________ 

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Docket No. 14-05 

Issued: May 5, 2014 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

RICHARD J. DASCHBACH, Chief Judge 

MICHAEL E. GROOM, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On October 3, 2013 appellant filed a timely appeal from a September 11, 2013 merit 

decision of the Office of Workers’ Compensation Programs (OWCP) denying his traumatic 

injury claim. Pursuant to the Federal Employees’ Compensation Act1

 (FECA) and 20 C.F.R. 

§§ 501.2(c) and 501.3, the Board has jurisdiction over the merits of this case. 

ISSUE 

The issue is whether appellant met his burden of proof to establish that he sustained a 

traumatic injury in the performance of duty on March 5, 2012. 

FACTUAL HISTORY 

This case was previously before the Board. By decision dated September 4, 2013, the 

Board set aside OWCP’s September 17, 2012 decision to find that appellant established that the 

 1

 5 U.S.C. § 8101 et seq.
2

March 5, 2012 incident occurred in time, place and manner alleged.2 It remanded the case for 

OWCP to evaluate the medical evidence. The findings of fact and conclusions of law from the 

prior decision are hereby incorporated by reference. 

Appellant submitted a March 5, 2012 urgent care report from a nurse at the Veterans 

Affairs (VA) Hospital who noted that he fell and suffered facial and oral trauma. The report 

advised that he ambulated with a limp and his right foot stuck on the tile flooring. 

In a March 5, 2012 diagnostic report, Dr. Gordon R. Schally, a Board-certified diagnostic 

radiologist, reported that a computerized tomography (CT) scan of the brain revealed no acute 

intracranial abnormalities and mild cerebral and cerebellar atrophy with findings most suggestive 

of mild chronic microvascular ischemic change. X-rays of the face revealed no fracture or other 

acute abnormalities with moderate amounts of dental work noted. 

In a March 5, 2012 diagnostic report, Dr. Marna J. Eissa, a Board-certified diagnostic 

radiologist, reported that a mandible report revealed no displaced mandible fracture. She 

recommended a dedicated facial bone CT scan due to suspicion of small fracture. Dr. Eissa 

noted no upper teeth were missing. 

In a March 5, 2012 urgent care report, Dr. Vernon E. Chee, Board-certified in internal 

medicine, reported that appellant presented to urgent care after he fell. Appellant recalled 

walking in the hallway, then his left leg “gave out,” causing him to fall forward and strike his 

face on the floor. He thought he lost consciousness, was dizzy and stayed on the floor for about 

10 minutes. Appellant reported a history of muscle weakness and numbness in the left lower 

extremity, which sometimes caused him to trip while walking. A CT scan of the brain showed 

no acute intracranial abnormalities and x-rays revealed no fractures. Dr. Chee diagnosed trauma 

to the face, mouth and teeth, noting that appellant had several loose teeth. After returning from 

radiology, appellant was missing tooth 8 and part of 7 and 10. Dr. Chee reported that appellant 

sneezed and the tooth flew out. He noted that the other teeth were loose but remained in place 

and the bleeding had slowed. Dr. Chee reported that appellant could resume work on March 12, 

2012 and referred him to VA Dental Clinic. 

In a March 5, 2012 report, Dr. Georgia K. McDonald, a dentist, reported that appellant 

presented to the dental clinic for an emergency visit after he fell on the job. Appellant was last 

seen three years ago by another dentist for a dental extraction for decay. Recently, a tooth on the 

upper right had “fallen out on its own” and the extraction socket was still healing in the position 

of tooth 4. Dr. McDonald noted a medical history of osteoarthritis, particularly in the left leg. 

Appellant stated that he sometimes had difficulty walking when his leg got stiff. 

On clinical examination, Dr. McDonald a noted fracture of tooth 9 with partial 

exfoliation, a crack on the root of tooth 10 probable and probable fracture of right porcelain 

fused to metal bridge on the upper right. Examination and clinical evaluation of radiographs 

demonstrated chronic generalized advanced periodontitis with poor demonstrated homecare of 

 2

 Docket No. 13-917 (issued September 4, 2013). The Board notes that appellant established that he suffered a 

fall on the morning of March 5, 2012. The Board found that the factual evidence of record was insufficient to 

establish that his fall was idiopathic. 
3

the teeth in need of restorative repair. Mobility of the upper and lower anterior teeth could not 

be definitively determined to have been caused by the fall. Dr. McDonald noted that the 

mobility could be anatomic and pathologic in nature due to the 80 to 90 present horizontal bone 

loss and attachment loss on those teeth. She reported fractured facial aspects and a loose bridge 

from number tooth 8 to 6. Dr. McDonald also noted a residual root tip on tooth 9, which was 

probably a result of fracture from the fall. Appellant stated that he just “spit the tooth out” and 

could not find it. Radiographs showed periapical infection on tooth 14 and 8, which would have 

been there before today. Dr. McDonald also noted semilunar lip laceration approximately 3/4 of 

an inch. She recommended that tooth 6, 8, 9 and the 10 residual root tip be removed for suture 

of oral/facial wounds and lacerations.3 

The employing establishment issued appellant a properly completed Form CA-16, 

authorization for examination, dated March 6, 2012. Appellant was authorized to visit 

Dr. James A. Campo, a dentist, at Campo Dentistry. 

By decision dated September 11, 2013, OWCP denied appellant’s claim on the grounds 

that the evidence was insufficient to establish that the March 5, 2012 employment incident 

caused his injuries. It noted that the reports of Dr. McDonald and Dr. Chee failed to explain how 

the conditions they diagnosed were caused by his fall on March 5, 2012. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of establishing the essential 

elements of his or her claim, including the fact that the individual is an “employee of the United 

States” within the meaning of FECA; that the claim was filed within the applicable time 

limitation; that an injury was sustained while in the performance of duty as alleged and that any 

disability or specific condition for which compensation is claimed are causally related to the 

employment injury.4 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or occupational disease.5

In order to determine whether an employee actually sustained an injury in the 

performance of duty, OWCP begins with an analysis of whether fact of injury has been 

established. Generally, fact of injury consists of two components which must be considered in 

conjunction with one another. The first component to be established is that the employee 

actually experienced the employment incident which is alleged to have occurred.6

 The second 

component is whether the employment incident caused a personal injury and generally can be 

established only by medical evidence. 

To establish a causal relationship between the condition, as well as any attendant 

disability claimed and the employment event or incident, the employee must submit rationalized 

 3

 This report was also signed by Dr. Shemika L. Sample, a dentist. 

4 Gary J. Watling, 52 ECAB 278 (2001); Elaine Pendleton, 40 ECAB 1143, 1154 (1989). 

5 Michael E. Smith, 50 ECAB 313 (1999). 

6 Elaine Pendleton, supra note 4. 
4

medical opinion evidence based on a complete factual and medical background, supporting such 

a causal relationship.7

 The opinion of the physician must be based on a complete factual and 

medical background of the claimant, must be one of reasonable medical certainty and must be 

supported by medical rationale explaining the nature of the relationship between the diagnosed 

condition and the specific employment factors identified by the claimant. This medical opinion 

must include an accurate history of the employee’s employment injury and must explain how the 

condition is related to the injury. The weight of medical evidence is determined by its reliability, 

its probative value, its convincing quality, the care of analysis manifested and the medical 

rationale expressed in support of the physician’s opinion.8

ANALYSIS 

Appellant established that the March 5, 2012 incident occurred as alleged when he fell at 

work. OWCP denied his claim on the grounds that it lacked sufficient medical evidence to 

support that his injuries were medically related to the March 5, 2012 employment incident. The 

Board finds that appellant did not submit sufficient medical evidence to support that he sustained 

an injury causally related to the March 5, 2012 employment incident.9

 

In a March 5, 2012 diagnostic report, Dr. Schally reported that a CT scan of the brain 

revealed no acute intracranial abnormalities and mild cerebral and cerebellar atrophy with 

findings most suggestive of mild chronic microvascular ischemic change. X-rays of the face 

revealed no fracture or other acute abnormalities. In a March 5, 2012 diagnostic report, Dr. Eissa 

reported that a mandible report revealed no displaced mandible fracture. While the reports of 

Dr. Schally and Dr. Eissa provide imaging results from diagnostic tests, the physicians did not 

provide any opinion on causal relationship to the accepted incident. These diagnostic studies are 

not sufficient to establish appellant’s claim. 

In a March 5, 2012 report, Dr. Chee stated that appellant presented to urgent care after he 

fell. Appellant was walking in a hallway when his left leg “gave out,” causing him to fall 

forward and strike his face on the floor. A CT scan of the brain showed no acute intracranial 

abnormalities and x-rays revealed no fractures. Dr. Chee diagnosed trauma to the face, mouth 

and teeth, noting that appellant had several loose teeth. After returning from radiology, appellant 

was missing tooth 8 and part of tooth 7 and 10. He reported that he sneezed and the tooth flew 

out. Dr. Chee noted that the other teeth were loose but remained in place and the bleeding had 

slowed. The Board finds that his report is not sufficient to establish appellant’s claim. Dr. Chee 

failed to provide any opinion regarding the cause of appellant’s condition. This renders his 

report of limited probative value.10 

In a March 5, 2012 report, Dr. McDonald reported that appellant presented to the dental 

clinic for an emergency visit after he fell on the job. Appellant was last seen three years prior by 

 7 See 20 C.F.R. § 10.110(a); John M. Tornello, 35 ECAB 234 (1983). 

8 James Mack, 43 ECAB 321 (1991). 

9 See Robert Broome, 55 ECAB 339 (2004).

10 S.W., Docket No. 08-2538 (issued May 21, 2009). 
5

another dentist for a dental extraction for decay. On examination Dr. McDonald noted a fracture 

of tooth 9 with partial exfoliation, crack on root of tooth 10 probable and probable fracture of 

right porcelain fused to metal bridge on the upper right. Examination and clinical evaluation of 

radiographs demonstrated chronic generalized advanced periodontitis with poor demonstrated 

homecare of the teeth in need of restorative repair. Mobility of the upper and lower anterior 

teeth could not be definitively determined to have been caused by the fall. Dr. McDonald noted 

that the mobility could be anatomic and pathologic in nature due to the 80 to 90 present 

horizontal bone loss and attachment loss on those teeth. She reported fractured facial aspects and 

loose bridge from number tooth 8 to 6. Dr. McDonald also noted residual root tip on tooth 9, 

which was probably a result of fracture from the fall. Appellant stated that he just “spit the tooth 

out” and could not find it. Radiographs showed periapical infection on tooth 14 and 8, which 

would have been there before today. Dr. McDonald also noted semilunar lip laceration 

approximately 3/4 of an inch. She recommended that tooth 6, 8, 9 and 10 residual root tip be 

removed and diagnosed suture of oral/facial wounds and lacerations. 

The Board notes that, while Dr. McDonald diagnosed of oral/facial wounds, fractured 

facial aspects, fracture of teeth, crack of teeth root, loose bridges, residual root tips, missing teeth 

and a semilunar lip laceration approximately 3/4 of an inch, she did not adequately address how 

the findings on examination were caused or contributed to by appellant’s fall at work. 

Dr. McDonald noted advanced periodontitis with poor demonstrated homecare of the teeth in 

need of restorative repair. Mobility of the upper and lower anterior teeth could not be 

definitively determined to have been caused by the fall, which could be anatomic and pathologic 

in nature due to the 80 to 90 present horizontal bone loss and attachment loss on those teeth. 

Dr. McDonald’s opinion is whether appellant’s dental and facial injuries were caused or 

aggravated by the March 5, 2012 work incident is therefore speculative in nature.11 

To be of probative value, a physician’s opinion on causal relationship should be one of 

reasonable medical certainty.12 Dr. McDonald’s statement fails to provide a definitive opinion 

that the findings on examination were caused by the March 5, 2012 incident. Medical reports 

without adequate rationale on causal relationship are of diminished probative value and do not 

meet an employee’s burden of proof.13 The opinion of a physician supporting causal relationship 

must rest on a complete factual and medical background supported by affirmative evidence, 

address the specific factual and medical evidence of record and provide medical rationale 

explaining the relationship between the diagnosed condition and the established incident or 

factor of employment.14 Without medical reasoning explaining how March 5, 2012 employment 

incident caused or contributed to his dental, facial and oral trauma, her report is insufficient to 

meet his burden of proof.15

 11 See Michael R. Shaffer, 55 ECAB 339 (2004). 

12 See Beverly R. Jones, 55 ECAB 411 (2004). 

13 Ceferino L. Gonzales, 32 ECAB 1591 (1981). 

14 See Lee R. Haywood, 48 ECAB 145 (1996). 

15 C.B., Docket No. 08-1583 (issued December 9, 2008). 
6

The March 5, 2012 urgent care reports from the VA Hospital nurses are also insufficient 

to establish appellant’s claim. A nurse is not a physician as defined under FECA and their 

reports are of no probative value.16

In the instant case, appellant has established that the March 5, 2012 incident occurred as 

alleged. The record, however, is without rationalized medical evidence on the causal 

relationship between the accepted March 5, 2012 employment incident and his diagnosed 

conditions. Thus, appellant has failed to establish his claim.17

The Board notes that where, as in this case, an employing establishment properly 

executes a Form CA-16, which authorizes medical treatment as a result of an employee’s claim 

for an employment-related injury, the CA-16 form creates a contractual obligation, which does 

not involve the employee directly, to pay for the cost of the examination or treatment regardless 

of the action taken on the claim.18 The period for which treatment is authorized by a CA-16 

form is limited to 60 days from the date of issuance, unless terminated earlier by OWCP.19 

Although OWCP adjudicated appellant’s claim of injury, it did not address the issue of 

reimbursement pursuant to this CA-16 form. The record is silent as to whether OWCP paid for 

the cost of his examination or treatment for the period noted on the form. 

The regulations provide that in unusual or emergency circumstances OWCP may approve 

payment for medical expenses incurred otherwise than as authorized in section 10.303. It may 

approve payment for medical expenses incurred even if a CA-16 form authorizing medical 

treatment and expenses has not been issued and the claim is subsequently denied; payment in 

such situations must be determined on a case-by-case basis.20 In this case, appellant was 

transported to the emergency room for examination immediately after the employment incident. 

The employing establishment provided appellant with a CA-16 form within a week of the 

employment incident. In denying appellant’s claim for a traumatic injury, OWCP did not 

address whether emergency circumstances or unusual circumstances were present or whether this 

was a situation in which reimbursement of medical expenses was appropriate.21 It is required to 

exercise its discretion to determine whether medical care has been authorized or whether 

unauthorized medical care involved emergency or unusual circumstances.22 The circumstances 

of the case warrant additional development of this issue. The case shall be remanded to OWCP 

 16 5 U.S.C. § 8102(2) of FECA provides as follows: “(2) ‘physician’ includes surgeons, podiatrists, dentists, 

clinical psychologists, optometrists, chiropractors and osteopathic practitioners within the scope of their practice as 

defined by State law.” 

17 C.P., Docket No. 13-831 (issued July 12, 2013). 

18 See Tracy P. Spillane, 54 ECAB 608 (2003). 

19 See 20 C.F.R. § 10.300(c). 

20 Id. at 10.304. 

21 P.S., Docket No. 10-1560 (issued June 23, 2011). 

22 Michael L. Malone, 46 ECAB 957 (1995). See Herbert J. Hazard, 40 ECAB 973 (1989). 
7

for further development consistent with this decision of the Board, followed by an appropriate 

decision.23

CONCLUSION 

The Board finds that appellant did not meet his burden of proof to establish that his 

diagnosed facial and oral conditions are causally related to the March 5, 2012 employment 

incident, as alleged. The case will be returned to OWCP for consideration of whether appellant’s 

medical expenses related to his treatment from the March 5, 2012 incident should be reimbursed. 

ORDER 

IT IS HEREBY ORDERED THAT the September 11, 2013 decision of the Office of 

Workers’ Compensation Programs is affirmed. The case is remanded for further development 

consistent with this decision of the Board. 

Issued: May 5, 2014 

Washington, DC 

 

 Richard J. Daschbach, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Michael E. Groom, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board 

 23 A.F., Docket No. 13-520 (issued May 17, 2013).