United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

D.W., Appellant

and

NATIONAL ARCHIVES & RECORDS 

ADMINISTRATION, Suitland, MD, Employer

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Docket No. 18-0644

Issued: November 15, 2018

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 February 5, 2018 appellant filed a timely appeal from January 3, 2018 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.1

ISSUE

The issue is whether appellant has met his burden of proof to establish total disability 

beginning July 17, 2017 causally related to his May 17, 2017 employment injury.

 

1 The Board notes that appellant submitted new evidence with his appeal. However, “The Board’s review of a case 

is limited to the evidence in the case record that was 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 evidence for the first time on appeal.
2

FACTUAL HISTORY

On June 6, 2017 appellant, then a 45-year-old archives technician, filed a traumatic injury 

claim (Form CA-1) alleging that on May 17, 2017 he sustained a low back injury as a result of 

pulling heavy boxes weighing up to 65 pounds and placing them on a platform while on a ladder 

at work. He stopped work on the date of injury. OWCP accepted the claim on July 27, 2017 for 

strain of the back wall of the thorax muscle and tendon. Appellant initially received continuation 

of pay benefits. OWCP paid wage-loss compensation and medical benefits for intermittent periods 

of disability commencing July 17, 2017. 

In a June 25, 2017 work capacity evaluation (Form OWCP-5c), Dr. Girish Rao, an 

internist, advised that, while appellant could not return to his usual job, he could work eight hours 

a day with certain restrictions as of June 28, 2017. He related that appellant’s restrictions would 

remain in place from June 28 until July 12, 2017. 

In a certificate of disability dated August 3, 2017, Dr. Dennis A. Carlini, a Board-certified 

orthopedic surgeon, noted that appellant was disabled through August 24, 2017. 

On September 15, 2017 appellant filed two claims for compensation (Form CA-7) for leave 

without pay (LWOP) for the period July 17 to September 15, 2017.

By development letter dated September 18, 2017, OWCP advised appellant that additional 

medical evidence was necessary to support his claim for disability benefits. It afforded him 30 

days to submit the necessary evidence.

In a September 7, 2017 attending physician’s report (Form CA-20), Dr. Carlini diagnosed 

disc herniation at L5 and indicated, by checking a box marked “yes,” that the diagnosed condition 

was caused or aggravated by an employment activity. He noted that appellant had no issues prior 

to the event. Dr. Carlini indicated that appellant was totally disabled from work from August 4 to 

October 5, 2017. 

On September 29, 2017 appellant filed another Form CA-7 for compensation for LWOP 

for the period September 18 to 29, 2017. 

On October 3, 2017 OWCP referred appellant, together with a statement of accepted facts 

(SOAF), the medical record, and a list of questions, to Dr. Matthew Drake, a Board-certified 

orthopedic surgeon, to determine whether he had residuals from his accepted conditions and to 

determine if he had continuing disability. The examination was scheduled for October 31, 2017 

at 10:00 a.m. On November 1, 2017 OWCP was advised by its medical scheduler that appellant 

did not keep the scheduled appointment with Dr. Drake.

On October 16, 2017 appellant filed a claim for compensation (Form CA-7) for LWOP for 

the period September 30 to October 10, 2017. 

In an October 9, 2017 letter, Dr. Carlini noted a history of appellant’s medical treatment.

He noted diagnoses of left-sided L5 radiculopathy and a central disc rupture at L4-5 and L5-S1. 

Dr. Carlini opined that appellant’s conditions were a direct result of the May 17, 2017 work injury. 
3

In a November 1, 2017 notice, OWCP proposed to suspend appellant’s wage-loss 

compensation and medical benefits as he failed to appear for the examination scheduled for 

October 31, 2017 with Dr. Drake. On November 9 and 21, 2017 appellant apologized to OWCP 

for missing his appointment with Dr. Drake and expressed his intent to reschedule the examination. 

In a work capacity evaluation (Form OWCP-5c) dated November 20, 2017, Dr. Carlini 

noted appellant’s accepted condition of strain of the muscle and tendon of the back wall of the 

thorax and advised that he could not perform his usual work or work with restrictions. He further 

advised that appellant had not reached maximum medical improvement (MMI). 

Appellant, on November 27, 2017, filed another claim for compensation (Form CA-7) for

LWOP for the period October 11 to November 24, 2017. 

OWCP, by letter dated December 5, 2017, advised appellant that his second opinion 

evaluation had been rescheduled for December 5, 2017 with Dr. Willie Thompson, a Boardcertified orthopedic surgeon. Appellant presented for the appointment.

In December 5, 2017 report, Dr. Thompson reviewed the SOAF and medical record. He 

noted appellant’s complaint of localized low back pain without radiculopathy and that lumbar 

epidural steroid injections had been recommended. Dr. Thompson provided a review of symptoms 

and findings on physical examination. He noted that appellant was a well-developed, wellnourished male who was in no acute distress. Dr. Thompson noted that he was alert and oriented. 

Appellant ambulated with a normal tandem gait. There was no evidence of a limp. On 

examination of the lumbar spine, Dr. Thompson reported full range of motion. There was no 

tenderness or paraspinous muscle spasms. Hee1-walking and toe-walking were performed 

adequately. Straight leg raising was negative bilaterally. No motor or sensory deficits were noted. 

The deep tendon reflexes were intact and equal bilaterally. The dorsalis pedis pulse was 3+ and 

regular. Manual muscle testing revealed strength to be graded at 5/5. There was normal muscle 

bulk and tone. Dr. Thompson noted that he did not have imaging studies available for review. He 

diagnosed soft tissue sprain/strain-type injury to the lower back. Dr. Thompson indicated that 

appellant had received adequate treatment. He saw no objective indication for need for additional 

treatment or diagnostic testing. Dr. Thompson advised that there was no evidence of continuing 

residuals of the May 17, 2017 employment injury. There were nonindustrial factors to consider. 

Dr. Thompson related that appellant’s prognosis was good. He opined that the recommended 

steroid injections were neither indicated nor would be beneficial. Dr. Thompson, in a Form 

OWCP-5c dated December 5, 2017, indicated that appellant could perform his usual job without 

restriction. He also indicated that appellant had reached MMI.

By decision dated January 3, 2018, OWCP denied appellant’s claim for disability 

compensation commencing July 17, 2017. It found that the weight of the medical evidence rested 

with Dr. Thompson’s opinion and concluded that appellant submitted insufficient medical 

evidence to establish that the claimed disability was related to the accepted May 17, 2017 

employment injuries. 
4

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of proof to establish essential 

elements of his or her claim by the weight of the evidence.2 For each period of disability claimed, 

the employee has the burden of proof to establish disability for work as a result of the accepted 

employment injury.3

Whether a particular injury causes an employee to be disabled for employment and the 

duration of that disability are medical issues which must be proved by a preponderance of the 

reliable, probative, and substantial medical evidence.4 Findings on examination are generally 

needed to support a physician’s opinion that an employee is disabled for work. When a physician’s 

statements regarding an employee’s ability to work consist only of repetition of the employee’s 

complaints that he hurts too much to work, without objective findings of disability being shown, 

the physician has not presented a medical opinion on the issue of disability or a basis for payment 

of compensation.5 The Board will not require OWCP to pay compensation for disability in the 

absence of medical evidence directly addressing the specific dates of disability for which 

compensation is claimed. To do so would essentially allow employees to self-certify their 

disability and entitlement to compensation.6

Causal relationship is a medical issue and the medical evidence required to establish causal 

relationship is rationalized medical evidence.7 Rationalized medical evidence is medical evidence 

which includes a physician’s detailed medical 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.8 Neither the fact that a disease or condition 

manifests itself during a period of employment nor the belief that the disease or condition was 

caused or aggravated by employment factors or incidents is sufficient to establish causal 

relationship.9

 

2 See Amelia S. Jefferson, 57 ECAB 183 (2005); see also Nathaniel Milton, 37 ECAB 712 (1986).

3 See Amelia S. Jefferson, id.

4 See Fereidoon Kharabi, 52 ECAB 291 (2001); see also A.C., Docket No. 17-1296 (issued February 15, 2018). 

5

Id.

6

Id.

7

Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).

8 Leslie C. Moore, 52 ECAB 132 (2000).

9 Dennis M. Mascarenas, 49 ECAB 215 (1997).
5

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish employmentrelated total disability commencing July 17, 2017 causally related to his accepted employment 

injury.

10

Appellant was initially treated by Dr. Rao. In a June 25, 2017 report, Dr. Rao related that 

appellant could return to work on June 28, 2017 with restrictions. He also related that these 

restrictions would be in place until July 12, 2017. Dr. Rao did not report that appellant would be 

disabled after July 17, 2017. As previously noted, OWCP is not required to pay compensation for 

disability in the absence of medical evidence directly addressing the specific dates of disability for 

which compensation is claimed.11 As Dr. Rao’s report does not address appellant’s disability 

status as of July 17, 2017 it is insufficient to establish appellant’s claim for wage-loss benefits 

commencing on that date. 

Appellant relies upon the medical opinions of Dr. Carlini to establish that his disability 

from work during the claimed period was due to his accepted May 17, 2017 work injuries. In 

several reports, Dr. Carlini examined appellant and found that he had lumbar radiculopathy, that 

the condition was causally related to the May 17, 2017 employment injury, and that he was unable 

to work during an intermittent period August 4 to November 20, 2017. The Board notes that 

OWCP has not accepted the diagnosis of lumbar radiculopathy as causally related to the accepted 

May 17, 2017 employment injuries. OWCP has only accepted strain of the muscle and tendon of 

the back wall of the thorax and a lumbar strain in this case. For conditions not accepted by OWCP 

as being employment related, it is the employee’s burden to provide rationalized medical evidence 

sufficient to establish causal relationship.12 None of the reports from Dr. Carlini contain rationale 

explaining how this condition had been caused or aggravated by the accepted May 17, 2017 

employment injuries. Moreover, Dr. Carlini did not offer a specific medical opinion addressing 

whether appellant’s disability from work during the claimed period was causally related to the 

accepted work injuries.13 Thus, for these reasons, his reports are insufficient to meet appellant’s 

burden of proof. 

In his December 5, 2017 report, Dr. Thompson, OWCP’s second opinion physician, 

opined that appellant had no residuals of the May 17, 2017 employment injuries and he had 

reached MMI, that he could perform his usual job without restriction, and that no further medical 

treatment was necessary. He examined appellant and noted full range of motion of the lumbar 

spine. Dr. Thompson found no tenderness or paraspinous muscle spasms. He reported that heelwalking and toe-walking were performed adequately, that straight leg raising was negative 

bilaterally, and no motor or sensory deficits were noted. Dr. Thompson further reported that deep 

tendon reflexes were intact and equal bilaterally and that the dorsalis pedis pulse was 3+ and 

 

10 Alfredo Rodriguez, 47 ECAB 437 (1996).

11 Supra note 5. 

12 G.A., Docket No. 09-2153 (issued June 10, 2010); Jaja K. Asaramo, 55 ECAB 200 (2004); Alice J. Tysinger, 51 

ECAB 638 (2000).

13 Id.
6

regular. He related that manual muscle testing revealed strength to be graded at 5/5 and that there 

was normal muscle bulk and tone. Dr. Thompson diagnosed soft tissue sprain/strain-type injury 

to the lower back for which appellant received adequate treatment. He determined that there was 

no evidence of any residuals of the May 17, 2017 employment injury or objective indication for 

need for additional treatment or diagnostic testing. Dr. Thompson concluded that appellant’s 

prognosis was good. 

The Board finds that Dr. Thompson’s report represents the weight of the medical evidence 

and establishes that appellant was not totally disabled as of the date of his examination due to his 

accepted May 17, 2017 employment injury. Dr. Thompson’s opinion is based on a proper factual 

and medical history as he reviewed the SOAF and medical record. He also related his

comprehensive examination findings in support of his opinion that appellant could work without 

restrictions. 

As noted, appellant must submit reasoned medical evidence directly addressing the specific 

dates of disability for work for which he claims compensation.14 He did not provide medical 

evidence containing a rationalized opinion supporting that he could not work beginning July 17, 

2017 due to his accepted conditions, and thus did not meet his burden of proof.

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 has not met his burden of proof to establish total disability 

commencing July 17, 2017 causally related to his May 17, 2017 employment injury.

 

14 See K.A., Docket No. 16-0592 (issued October 26, 2016).
7

ORDER

IT IS HEREBY ORDERED THAT the January 3, 2018 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: November 15, 2018

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