United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

P.B., Appellant 

and 

DEPARTMENT OF JUSTICE, BUREAU OF 

PRISONS, METROPOLITAN DETENTION 

FACILITY, Brooklyn, NY, Employer 

__________________________________________ 

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Docket No. 15-1461 

Issued: October 9, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On June 29, 2015 appellant filed a timely appeal from a January 5, 2015 merit decision of 

the Office of Workers’ Compensation Programs (OWCP). 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 a cervical spine injury 

in the performance of duty. 

FACTUAL HISTORY 

On July 30, 2013 appellant, then a 45-year-old engineering technician, filed a traumatic 

injury claim (Form CA-1) alleging that on July 29, 2013 he injured the left side of his neck, with 

 1

 5 U.S.C. § 8101 et seq. 
2

pain radiating into his left shoulder and upper extremity, when he attempted to lift a case of 

paper. He stopped work on July 30, 2013. 

Dr. Neal Smith, an attending Board-certified orthopedic surgeon, provided July 30 and 

August 5, 2013 work absence slips diagnosing left cervical radiculitis with a possible cervical 

disc herniation. He prescribed medication.2 Dr. Smith held appellant off work from July 30 to 

September 2, 2013. 

In an August 22, 2013 letter, OWCP advised appellant of the additional evidence needed 

to establish his claim, including a description of the work factors believed to have caused the 

claimed injury, and a narrative report from his attending physician explaining how and why the 

work factors would cause the diagnosed injury. 

In response, appellant provided his September 3, 2013 statement explaining that on 

July 29, 2013 the case of paper he was lifting fell forward, causing a “pull and pain” in his neck. 

The pain worsened overnight, radiating into the left shoulder and arm. 

Appellant also provided new treatment notes.3 In a July 30, 2013 report, Dr. Smith 

related appellant’s account of left-sided neck pain after lifting a case of paper at work. On 

examination he found limited, painful cervical motion. Dr. Smith obtained x-rays demonstrating 

a normal cervical alignment. He diagnosed acute left-sided cervical radiculitis with a possible 

herniated disc. On August 5, 2013 Dr. Smith diagnosed persistent left-sided cervical radiculitis. 

He prescribed physical therapy.4 As appellant’s symptoms improved as of September 6, 2013, 

Dr. Smith released him to light duty. He diagnosed persistent left-sided cervical radiculitis, a 

small central disc herniation at C4-5, and a left-sided disc herniation at C5-6.5

By decision dated October 4, 2013, OWCP denied the claim, finding that appellant did 

not establish causal relationship. It accepted that the July 29, 2013 lifting incident occurred at 

the time, place, and in the manner alleged. OWCP found, however, that appellant did not 

provide medical evidence supporting that the incident caused the diagnosed cervical radiculitis or 

herniated cervical discs. 

Appellant disagreed and, in a November 3, 2013 letter, requested a telephonic hearing 

before an OWCP hearing representative. He provided a September 10, 2013 light-duty job offer 

from the employing establishment, which appellant accepted on September 12, 2013. Appellant 

also submitted copies of Dr. Smith’s reports previously of record. 

By decision dated April 15, 2014, an OWCP hearing representative set aside the 

October 4, 2013 decision, and remanded the case to obtain a supplemental report from Dr. Smith 

 2

 OWCP assigned a medical management nurse to appellant’s case on August 20, 2013. In an August 22, 2013 

closure report, the nurse reported that Dr. Smith referred appellant to a pain management specialist for an epidural 

injection. 

3

 Appellant also submitted an August 27, 2013 treatment note lacking a legible signature. 

4

 Appellant submitted physical therapy notes dated from August 8 to 29, 2013. 

5

 An August 12, 2013 magnetic resonance imaging scan showed a mild central disc protrusion at C4-5 and a leftsided C5-6 paracentral and foraminal disc protrusion mildly compressing the spinal cord and left lateral recess. 
3

addressing any causal relationship between the accepted July 29, 2013 lifting incident and the 

claimed cervical spine injury. 

In an April 28, 2014 letter, OWCP requested that Dr. Smith provide a “supplemental 

report with a detailed well-rationalized opinion regarding any causal relationship” between the 

July 29, 2013 lifting incident and the claimed injury. In response, Dr. Smith submitted a 

May 13, 2014 report diagnosing a herniated intervertebral disc. He opined that the July 29, 2013 

lifting incident was “the competent cause of the injury. [Appellant’s] complaints [were] 

consistent with the injury. [His] history of the injury is consistent with [the doctor’s] objective 

findings.” 

By decision dated May 27, 2014, OWCP denied the claim as causal relationship was not 

established. It found that the medical evidence did not include “medical rationale which explains 

how lifting a case of paper caused or aggravated the diagnosed condition of herniated cervical 

intervertebral disc.” 

Appellant disagreed and, in a June 3, 2014 letter, requested a review of the written 

record. He also submitted a duplicate copy of Dr. Smith’s May 13, 2014 report. 

By decision dated January 5, 2015, an OWCP hearing representative affirmed the 

May 27, 2014 decision, finding that causal relationship was not established. He found that 

Dr. Smith failed to explain “how and why lifting a case of paper caused or contributed to the 

diagnosed cervical condition.” 

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

employment injury.6 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or an occupational disease.7

In order to determine whether an employee sustained a traumatic 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 that must be considered 

conjunctively. First, the employee must submit sufficient evidence to establish that he or she 

actually experienced the employment incident that is alleged to have occurred.8

 An employee 

has not met his or her burden of proof in establishing the occurrence of an injury when there are 

such inconsistencies in the evidence as to cast serious doubt upon the validity of the claim.9

 

 6 Joe D. Cameron, 41 ECAB 153 (1989). 

7 See Irene St. John, 50 ECAB 521 (1999); Michael E. Smith, 50 ECAB 313 (1999). 

8 Gary J. Watling, 52 ECAB 278 (2001). 

9 S.N., Docket No. 12-1222 (issued August 23, 2013); Tia L. Love, 40 ECAB 586, 590 (1989). 
4

Second, the employee must submit sufficient evidence, generally only in the form of medical 

evidence, to establish that the employment incident caused a personal injury.10 

The medical evidence required to establish causal relationship is generally rationalized 

medical opinion evidence. Rationalized medical opinion evidence is medical evidence which 

includes a physician’s rationalized opinion on the issue of whether there is a causal relationship 

between the claimant’s diagnosed condition and the implicated employment factors. 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.11

ANALYSIS 

Appellant claimed that he sustained a cervical spine injury with left upper extremity 

symptoms when he tried to lift a case of paper on July 29, 2013. OWCP accepted that the 

July 29, 2013 incident occurred as alleged, but denied the claim as the medical evidence did not 

establish a causal relationship between those factors and the claimed neck injury. 

In support of his claim, appellant submitted reports from Dr. Smith, an attending Boardcertified orthopedic surgeon. In reports from July 30 to August 5, 2013, Dr. Smith diagnosed 

left-sided cervical radiculitis. On September 6, 2013 he also diagnosed a left-sided disc 

herniation at C5-6. Dr. Smith provided a May 13, 2014 supplemental report noting that the 

July 29, 2013 incident caused the claimed injury, that appellant’s presentation was consistent 

with the injury, and that the history of injury was consistent with clinical findings. While 

Dr. Smith consistently opined that the accepted July 29, 2013 employment incident caused 

cervical radiculitis or a herniated cervical disc, he did not provide his medical reasoning 

supporting his opinion. Dr. Smith did not set forth the medical mechanics whereby attempting to 

lift a case of paper would cause a herniated cervical disc or cervical radiculitis. Because he did 

not provide such rationale, Dr. Smith’s opinion is insufficient to establish causal relationship in 

this case.12 

OWCP advised appellant by August 22, 2013 letter of the necessity of providing a 

narrative report from his attending physician with medical rationale supporting causal 

relationship. It also requested a supplemental report from Dr. Smith addressing causal 

relationship. As appellant did not provide such evidence, OWCP’s January 5, 2015 decision 

denying the claim is proper under the law and facts of the case. 

On appeal appellant contends that he had supplied the requested documentation to the 

best of his ability. He asserts that Dr. Smith’s May 13, 2014 report contained sufficient medical 

rationale to establish causal relationship. Appellant notes that Dr. Smith’s staff advised him that 

a more detailed report would cost more than $1,000.00. He claimed, and OWCP accepted, that 

 10 Deborah L. Beatty, 54 ECAB 340 (2003).

11 Solomon Polen, 51 ECAB 341 (2000). 

12 Supra note 10.
5

he attempted to lift a case of paper at work on July 29, 2013. However, it remains appellant’s 

burden to provide medical evidence establishing that this incident caused the claimed cervical 

spine injury. In his multiple reports, Dr. Smith generally supported causal relationship, but did 

not set forth his medical reasoning as to why lifting a case of paper would cause the diagnosed 

herniated intervertebral disc. Therefore, appellant did not provide sufficient medical evidence to 

establish his claim.13

Appellant may submit new evidence or argument with a written request for 

reconsideration to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128(a) 

and 20 C.F.R. §§ 10.605 through 10.607. 

CONCLUSION 

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

sustained a cervical spine injury in the performance of duty. 

ORDER 

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’ 

Compensation Programs dated January 5, 2015 is affirmed. 

Issued: October 9, 2015 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board 

 13 Appellant also submitted an August 27, 2013 treatment note lacking a legible signature. As this form lacks an 

identifiable physician’s signature, it does not constitute medical evidence. See Merton J. Sills, 39 ECAB 572, 

575 (1988).