United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

A.M., Appellant

and

DEPARTMENT OF JUSTICE, BUREAU OF 

PRISONS, FEDERAL DETENTION CENTER, 

Philadelphia, PA, Employer

__________________________________________

)

)

)

)

)

)

)

)

)

Docket No. 18-1098

Issued: April 22, 2019

Appearances: Case Submitted on the Record

Aaron B. Aumiller, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Chief Judge

PATRICIA H. FITZGERALD, Deputy Chief Judge

ALEC J. KOROMILAS, Alternate Judge

JURISDICTION

On April 30, 2018 appellant, through counsel, filed a timely appeal from a November 1, 

2017 merit decision of the Office of Workers’ Compensation Programs (OWCP).2 Pursuant to the 

 

1

In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for legal 

or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. § 501.9(e). 

No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An attorney or 

representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject to fine or 

imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation.

2 Under the Board’s Rules of Procedure, an appeal must be filed within 180 days from the date of issuance of an 

OWCP decision. An appeal is considered filed upon receipt by the Clerk of the Appellate Boards. See 20 C.F.R. 

§ 501.3(e)-(f). One hundred and eighty days from November 1, 2017, the date of OWCP’s last decision was 

April 30, 2018. Since using May 4, 2018, the date the appeal was received by the Clerk of the Appellate Boards would 

result in the loss of appeal rights, the date of the postmark is considered the date of filing. The date of the U.S. Postal 

Service postmark is April 30, 2018, rendering the appeal timely filed. See 20 C.F.R. § 501.3(f)(1).
2

Federal Employees’ Compensation Act3(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board 

has jurisdiction over the merits of this case.4

ISSUES

The issues are: (1) whether appellant has met her burden of proof to establish that 

acceptance of her claim should be expanded to include cervical and lumbar conditions causally 

related to the accepted September 15, 2015 employment injury; and (2) whether she has met her 

burden of proof to establish total disability for the period November 1 to 13, 2015 causally related 

to the accepted injury.

FACTUAL HISTORY

On September 21, 2015 appellant, then a 33-year-old senior officer specialist, filed a 

traumatic injury claim (Form CA-1) alleging that she sustained injuries to her mouth, left elbow, 

right little finger, and lower back on September 15, 2015 when escorting an inmate while in the 

performance of duty. She explained that the inmate became combative, hit her several times in 

the face and head, and pulled her hair. Appellant stopped work that day and returned to work on 

December 10, 2015 in a temporary alternative duty status. 

In the attending physicians report section of a September 24, 2015 authorization for 

examination and/or treatment (Form CA-16), Dr. Uplekh S. Purewal, a Board-certified 

anesthesiologist, reported that on September 15, 2015 appellant was struck on the face by a 

prisoner, she was wrestled to the ground, and her neck was forcefully turned. He diagnosed 

cervical radiculopathy based on a positive compression test and positive facet arthropathy.

In a development letter dated September 25, 2015, OWCP advised appellant that the 

medical evidence of record was insufficient to establish that her claimed cervical and lumbar 

conditions were causally related to the alleged employment incident. Appellant was requested to 

submit rationalized medical evidence supporting causal relationship between her diagnosed 

conditions and the September 15, 2015 employment incident. OWCP afforded her 30 days to 

submit the necessary evidence. 

Dr. Purewal noted in a September 30, 2015 report his examination findings for the cervical 

and lumbar spine as well as the upper and lower extremities. He opined that as a result of the 

September 15, 2015 employment injury, appellant developed aggravation and exacerbation of 

preexistent cervicalgia, aggravation and exacerbation of cervical facet syndrome, post-traumatic 

cervical radiculopathy, aggravation and exacerbation of preexistent lumbago, aggravation and 

 

3 5 U.S.C. § 8101 et seq.

4 The Board notes that following the November 1, 2017 decision and attached to her appeal, OWCP received 

additional evidence. However, the Board’s Rules of Procedure provides: “The Board’s review of a case is limited to 

the evidence that was in the case record before OWCP at the time of its final decision. Evidence not before OWCP 

will not be considered by the Board for the first time on appeal.” 20 C.F.R. § 501.2(c)(1). Thus, the Board is precluded 

from reviewing this additional evidence for the first time on appeal. Id. 
3

exacerbation of lumbar facet syndrome, clinical lumbar radiculopathy, post-traumatic muscle 

spasm, chronic pain syndrome due to trauma, and left elbow pain. 

An October 5, 2015 x-ray report of appellant’s left elbow indicated a normal radiographic 

appearance of the left elbow. 

In an October 15, 2015 report, Dr. Purewal noted that appellant reported immediate pain 

in her left arm and left elbow at the time of the September 15, 2015 employment incident. He also 

noted that her complaints of neck pain, numbness in fingers, midback (thoracic spine) pain, and 

lower back pain all began without major events. Dr. Purewal noted examination findings and 

again noted his prior assessments regarding appellant’s diagnosed conditions.

By decision dated November 2, 2015, OWCP found that appellant had not met her burden 

of proof to establish that her diagnosed cervical and lumbar conditions were causally related to or 

had been aggravated by the accepted September 15, 2015 employment incident. 

In November 3 and December 4 and 17, 2015 reports, Dr. Purewal continued to report that,

as a result of the September 15, 2015 employment incident, appellant developed the previously 

diagnosed multiple cervical and lumbar conditions. He reported that she had impacted her head, 

face, and left arm during the incident and that she immediately started to experience pain in her 

left arm and left elbow. Dr. Purewal also reported, however, that appellant’s neck, midback, and 

lower back pain began without major events.

In a November 3, 2015 employment capacity evaluation (Form OWCP-5c) Dr. Purewal 

indicated that appellant could perform light-duty work with restrictions. Following a 

November 16, 2015 functional capacity evaluation, he advised that she was able to perform lightduty work. On December 4 and 17, 2015 Dr. Purewal ordered magnetic resonance imaging (MRI) 

scans of the cervical spine, lumbar spine, and left elbow, as well as a electromyogram and nerve 

conduction velocity (EMG/NCV) study of the bilateral upper extremities due to continuing 

symptoms. 

On December 2, 2015 appellant requested an oral hearing before a representative of 

OWCP’s Branch of Hearings and Review.

In January 29 and February 26, 2016 reports, Dr. R. Todd Rinnier, an osteopath and Boardcertified anesthesiologist, reported appellant’s complaints of pain and that the neck pain, midback 

(thoracic spine), and lower back pain began without major events. He noted that she had been 

treated with pain medications and rest since the September 15, 2015 injury and that additional 

testing had been requested. Dr. Rinnier indicated that after the employment-related injury on 

September 15, 2015, appellant developed aggravation and exacerbation of preexistent cervicalgia,

aggravation and exacerbation of cervical facet syndrome, post-traumatic cervical radiculopathy,

aggravation and exacerbation of preexistent lumbago, aggravation and exacerbation of lumbar 

facet syndrome, clinical lumbar radiculopathy, post-traumatic muscle spasm, chronic pain 

syndrome due to trauma, and left elbow pain. 

In a March 25, 2016 report, Dr. Rinnier diagnosed, as evidenced by his interpretation of 

the March 2, 2016 MRI scans, a C5-6 disc herniation, abutting the ventral margin of the spinal 

cord; a T11-12 disc herniation, disc extrusion, with indentation of the thecal sac; and L5-S1 disc 
4

bulging, annular tear, impinging upon nerve root, with right neuroforaminal encroachment. He 

indicated that those conditions developed after the September 15, 2015 employment injury.

In an April 5, 2016 report, Dr. Rinnier reported that appellant was first evaluated by his

practice in June 2012 for neck pain, midback (thoracic spine) pain, and lower back pain and that 

she had received lumbar epidural injections, bilateral sacroiliac joint injections, radiofrequency 

ablation of medial branch nerves, and interventional pain management treatments. On 

September 30, 2015 appellant was reevaluated for an employment-related injury. Dr. Rinnier 

noted that she had indicated that, due to her employment incident, her head, face, and left arm were 

impacted and that she immediately experienced pain in her left arm and left elbow. Appellant also 

reported that her neck, midback, and lower back pain had been aggravated and exacerbated by the 

employment-related injury. Dr. Rinnier noted examination findings and results of diagnostic 

testing of the left elbow and cervical and lumbar spine. He opined that appellant’s disc herniation 

at C5-6 and disc herniation at T11-12, as evidenced by MRI scans, were permanent and attributable 

to the employment injury of September 15, 2015. Copies of the March 2, 2015 MRI scans of the 

cervical spine and lumbar spine were provided along with a June 5, 2012 MRI scan of the lumbar 

spine for comparison.

By decision dated April 21, 2016, an OWCP hearing representative reversed the 

November 2, 2015 decision and remanded the case to OWCP for acceptance of conditions of 

laceration, inside bottom of lip, left side; contusion, bottom of right eye orbit; and left elbow bruise. 

He noted that the evidence of record remained insufficient to accept cervical and thoracic 

conditions. 

By decision dated April 29, 2016, OWCP accepted the claim for contusion of eyeball and 

orbital tissues, right eye; contusion of left elbow; and laceration with foreign body of lip, consistent 

with the hearing representative’s decision. It, however, found that the medical evidence of record 

was insufficient to establish the acceptance of additional conditions, as the reports of Dr. Rinnier 

and Dr. Purewal did not provide medical rationale explaining causal relationship between the 

additional conditions and the accepted employment incident.

OWCP subsequently received an April 20, 2016 report, Ijeoma Menkiti, a certified nurse 

practitioner, related appellant’s findings regarding appellant’s current condition. 

An April 20, 2016 EMG/NCV study of the upper extremities revealed left cervical 

radiculopathy at C6-7.

On May 11, 2016 OWCP received a May 5, 2016 claim for compensation (Form CA-7) in 

which appellant sought wage-loss compensation for intermittent periods of leave used for the 

period November 1 through 28, 2015 and leave without pay continuously from November 29 

through December 12, 2015. A May 9, 2016 time analysis form (Form CA-7a) noted appellant 

sought disability compensation for the period November 1 through 13, 2015 and noted use of leave 

by appellant through December 9, 2015.

In a development letter dated May 16, 2016, OWCP noted that appellant’s physicians had 

not explained how the accepted conditions had resulted in temporary total disability for the periods 

claimed. It further noted that the submissions from Dr. Rinnier and Dr. Purewal contained 
5

insufficient medical rationale to accept the case for additional conditions. Appellant was informed 

of the type of medical evidence needed to establish her claim for compensation and afforded her 

30 days to submit the necessary evidence. 

By decision dated June 28, 2016, OWCP denied appellant’s claim for disability 

compensation for the period November 1 through December 9, 2015. It found that the medical 

evidence of record was insufficient to establish that she was disabled as a result of her accepted 

employment-related medical conditions. OWCP further found that medical reports from

Drs. Rinnier and Purewal were insufficient to establish that the additional conditions were causally

related to the accepted injury. 

On July 8, 2016 appellant, through counsel, requested a telephonic hearing before an 

OWCP hearing representative. A telephonic hearing was held on February 8, 2017, during which 

counsel contended that appellant’s herniated disc conditions should have been accepted.

In a December 2, 2016 report, Dr. Rinnier continued to opine that, after the September 15, 

2015 employment injury, appellant developed cervical and lumbar conditions. In a February 7, 

2017 report, he explained that she was first evaluated by his practice in June 2012 for neck, pain, 

midback (thoracic spine) pain, and lower back pain and noted her medical course. Dr. Rinnier

indicated that appellant was reevaluated on September 30, 2015 following an employment-related 

injury. He opined that her disc herniation at C5-6 and disc herniation at T11-12, as evidenced by 

MRI scans, were, within a reasonable degree of medical certainty, permanent and attributable to 

the employment incident. 

By decision dated March 13, 2017, an OWCP hearing representative modified the June 28, 

2016 decision to reflect that the period of disability claimed was from November 1 through 13, 

2015, but affirmed the denial of the claim as there was no medical evidence of record which

established that appellant’s claimed disability from November 1 through 13, 2015 was causally 

related to her accepted conditions. He further noted that the medical evidence of record failed to 

reflect sufficient medical evidence to support that disc herniations at C5-6 and T11-12 were 

causally related to the accepted September 15, 2015 employment incident and/or that appellant 

had experienced disability from November 1 through 13, 2015 causally related to the accepted 

September 15, 2015 employment incident. 

On August 3, 2017 appellant, through counsel, requested reconsideration of the March 13, 

2018 decision. Counsel referenced new evidence from Dr. Rinnier dated July 11, 2017 which he 

asserted established causal relationship for the cervical and thoracic conditions.

In the accompanying July 11, 2017 report, Dr. Rinnier reiterated the history of the injury,

noted appellant’s prior history of cervical and lumbar conditions, presented physical examination 

findings, and diagnosed post-traumatic cervicalgia, post-traumatic cervical facet syndrome, disc 

herniation at C5-6 from MRI scans, post-traumatic cervical radiculopathy, cervical radiculopathy 

at C6-7 from EMG study, disc herniation at T11-12 from MRI scan, aggravation and exacerbation 

of preexisting lumbago, lumbar facet syndrome and lumbar radiculopathy, post-traumatic muscle 

spasm, chronic pain syndrome due to trauma, and left elbow pain. He reiterated that these 

conditions developed after the September 15, 2015 employment injury. Dr. Rinnier explained that 

the altercation with the inmate was described as an impact to the head and face and had resulted 
6

in accepted conditions to the head and face. He advised that an impact to those areas, if strong 

enough, can flex or extend the neck in a way that can herniate an intervertebral disc (also known 

as a whiplash injury). Dr. Rinnier explained that a herniation causes arm pain (radiculopathy) as 

the disc presses on the nerves coming out of the spine. He concluded that appellant’s injuries were 

proximally caused by the employment-related injury. Dr. Rinnier opined that appellant’s disc 

herniation at C5-6 from MRI scans, disc herniation at T11-12 from MRI scans, and cervical 

radiculopathy at C6-7 from EMG study were permanent and causally related to the September 15, 

2105 employment injury for the reasons explained in his report.

By decision dated November 1, 2017, OWCP denied modification of its March 13, 2017 

decision finding that the evidence of record was insufficient to establish causal relationship 

between the accepted employment injury and her multiple diagnosed cervical and lumbar 

conditions as well as her alleged disability for the period November 1 to 13, 2015.

LEGAL PRECEDENT -- ISSUE 1

An employee seeking benefits under FECA has the burden of proof to establish 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 timely filed within the applicable 

time limitation period of FECA,5that an injury was sustained in the performance of duty as alleged, 

and that any disability or medical condition for which compensation is claimed is 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 upon a traumatic injury or an occupational disease.7

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether fact of injury has been established. There 

are two components involved in establishing fact of injury. First, the employee must submit 

sufficient evidence to establish that he or she actually experienced the employment incident at the 

time, place, and in the manner alleged. The second component is whether the employment incident 

caused a personal injury and generally can be established only by medical evidence.8 

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

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

opinion evidence sufficient to establish such causal relationship.9 Rationalized medical opinion 

 

5 S.B., Docket No. 17-1779 (issued February 7, 2018); J.P., 59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 

153 (1989).

6

J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 

ECAB 312 (1988).

7 K.M., Docket No. 15-1660 (issued September 16, 2016); L.M., Docket No. 13-1402 (issued February 7, 2014); 

Delores C. Ellyett, 41 ECAB 992 (1990).

8

John J. Carlone, 41 ECAB 354 (1989); see 5 U.S.C. § 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 10.5(q) 

(traumatic injury and occupational disease defined, respectively).

9 K.V., Docket No. 18-0723 (issued November 9, 2018).
7

evidence is required to establish causal relationship. The opinion of the physician must be based 

on a complete factual and medical background, 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.10

ANALYSIS -- ISSUE 1

The Board finds that this case is not in posture for decision. 

In a report dated July 11, 2017, Dr. Rinnier reiterated the history of appellant’s traumatic 

injury, noted her preexisting history of cervical and lumbar conditions, presented physical 

examination findings, and diagnosed post-traumatic cervicalgia, post-traumatic cervical facet 

syndrome, a disc herniation at C5-6 from MRI scans, post-traumatic cervical radiculopathy, 

cervical radiculopathy at C6-7 from EMG study, disc herniation at T11-12 from MRI scan, 

aggravation and exacerbation of preexisting lumbago, lumbar facet syndrome and lumbar 

radiculopathy, post-traumatic muscle spasm, chronic pain syndrome due to trauma, and left elbow 

pain. He reiterated that these conditions developed after the September 15, 2015 employment 

injury. 

Dr. Rinnier noted that appellant’s altercation with the inmate was an impact incident to her 

head and face sufficient to result in a lip laceration, a contusion of the right eye orbit, and a left 

elbow bruise. He explained that an impact to her head and neck areas, if strong enough, can flex 

or extend the neck in a way that can herniate an intervertebral disc (also known as a whiplash 

injury). Dr. Rinnier explained that such an injury then causes arm pain (radiculopathy) as the disc 

presses on the nerves coming out of the spine. He concluded that appellant’s injuries were 

proximally caused by the employment-related injury. Dr. Rinnier opined that her disc herniation 

at C5-6 from MRI scans, disc herniation at T11-12 from MRI scans, and cervical radiculopathy at 

C6-7 from EMG study were permanent and causally related to the September 15, 2105 

employment injury. 

The Board finds that while Dr. Rinnier’s opinion regarding causal relationship lacks 

sufficient medical rationale to meet appellant’s burden of proof to establish her claim, it was based 

upon an accurate medical history and provided medical rationale explaining how the forces of 

impact in the accepted employment injury could result in or have aggravated the diagnosed cervical 

and lumbar conditions. As such, the opinion of Dr. Rinnier is sufficient to require OWCP to further 

develop the medical evidence in this claim.

11

 

It is well established that proceedings under FECA are not adversarial in nature and OWCP 

is not a disinterested arbiter.12 While the claimant has the burden of proof to establish entitlement 

to compensation, OWCP shares responsibility in the development of the evidence and to see that 

 

10 I.J., 59 ECAB 408 (2008).

11 See R.H., Docket No. 17-1966 (issued March 6, 2018); John J. Carlone, 41 ECAB 354 (1989).

12 See A.M., Docket No. 18-0630 (issued December 10, 2018); Vanessa Young, 56 ECAB 575 (2004).
8

justice is done.13 Thus, the Board will remand the case to OWCP for further development of the 

medical evidence to obtain a rationalized medical opinion as to whether the accepted employment 

incident of September 15, 2015 was sufficient to have caused or aggravated cervical and lumbar 

conditions. As appellant reported that her preexisting neck, midback, and lower back pain had 

been aggravated and exacerbated by the employment-related injury, on remand, OWCP should 

prepare a statement of accepted facts which includes the accepted conditions of the case as well as 

appellant’s preexisting medical conditions and then obtain a second opinion examination on the 

issue of causal relationship. After such further development as may be deemed necessary, OWCP 

shall issue a de novo decision.14

CONCLUSION

The Board finds that this case is not in posture for decision. 

ORDER

IT IS HEREBY ORDERED THAT the November 1, 2017 decision of the Office of 

Workers’ Compensation Programs is set aside and the case is remanded for further action 

consistent with this decision.

Issued: April 22, 2019

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge

Employees’ Compensation Appeals Board

 

13 M.B., Docket No. 17-0536 (issued June 22, 2017); Donald R. Gervasi, 57 ECAB 281, 286 (2005); Jimmy A. 

Hammons, 51 ECAB 219 (1999); William J. Cantrell, 34 ECAB 1233, 1237 (1983). 

14 Given the disposition of Issue 1, Issue 2 is moot.