United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

A.T., Appellant

and

DEPARTMENT OF HOMELAND SECURITY, 

IMMIGRATION AND CUSTOMS 

ENFORCEMENT, San Diego, CA, Employer

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Docket No. 19-1608

Issued: April 21, 2020

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

PATRICIA H. FITZGERALD, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On July 23, 2019 appellant filed a timely appeal from a June 10, 2019 merit decision of the 

Office of Workers’ Compensation Programs (OWCP).1 Pursuant to the Federal Employees’

Compensation Act2(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 has met his burden of proof to establish that the acceptance 

of his claim should be expanded to include the additional conditions of cervical radiculitis and 

 

1 The Board notes that appellant submitted additional evidence on appeal. However, the Board’s Rules of 

Procedure provides: “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 additional evidence for 

the first time on appeal. Id

2

5 U.S.C. § 8101 et seq.
2

aggravation of cervical spinal stenosis as causally related to the accepted June 12, 2009 

employment injury.

FACTUAL HISTORY

This case has previously been before the Board.3 The facts and circumstances as set forth 

in the Board’s prior decisions are incorporated herein by reference. The relevant facts are as 

follows.

On June 15, 2009 appellant, then a 52-year-old special agent, filed a traumatic injury claim 

(Form CA-1) alleging that on June 12, 2009 he sustained injuries when a ladder he was climbing

collapsed while in the performance of duty. OWCP accepted the claim for closed left radius neck 

fracture. It subsequently expanded acceptance of the claim to include left shoulder impingement 

syndrome, left carpal tunnel syndrome, and resolved cervical sprain. Appellant underwent an 

OWCP-authorized left carpal tunnel release on January 21, 2010 and OWCP-authorized left 

shoulder arthroscopic surgery with excision of the distal clavicle on September 13, 2010. 

In a letter dated June 7, 2018, OWCP advised appellant of all his accepted conditions and

informed him that the requested medical services of acupuncture and physical therapy could not 

be authorized as they did not appear causally related to the accepted conditions. 

Appellant submitted evidence in response to OWCP’s June 7, 2018 letter.

In a report dated May 29, 2018, Dr. Larry D. Dodge, a Board-certified orthopedic surgeon, 

noted appellant was seen that day for persistent neck pain complaints with intermittent paresthesias 

into the upper extremities due to a June 12, 2009 injury. Appellant’s physical examination 

revealed paracervical area tenderness and spasm, moderate cervical pain at extremes of motion, 

pain greater in the right arm with neck extension, slight-to-moderately positive Spurling’s test, and 

full upper extremity range of motion. Dr. Dodge opined that appellant continued to suffer from 

cervical radiculopathy and cervical spondylosis. 

In a June 4, 2018 report, Dr. Tiffany L. Shay Alexander, a Board-certified occupational

medicine physician, noted a June 12, 2009 date of injury and that appellant was currently retired. 

She related that his physical examination findings included cervical paraspinal and cervical spine 

muscles tender on palpation, limited neck range of motion slight right upper extremity weakness 

with finger extension, and positive bilateral wrist Tinel’s sign. Dr. Shay Alexander diagnosed 

cervical radiculitis, cervical spinal stenosis, and bilateral carpal tunnel syndrome. She requested 

authorization for acupuncture and physical therapy to treat appellant’s neck pain, upper extremity 

paresthesias, and lack of range of motion. 

Dr. Shay Alexander, in a July 6, 2018 supplemental report, noted that on June 4, 2018 she 

had diagnosed cervical radiculitis, bilateral carpal tunnel syndrome, and cervical spinal stenosis. 

She again requested authorization for physical therapy and acupuncture to treat appellant’s lack of 

 

3 Docket No 16-0738 (issued May 19, 2016); Docket No. 15-0033 (issued March 2, 2015); Order Remanding Case, 

Docket No. 13-0781 (issued February 14, 2014). The Board’s prior decisions reviewed whether appellant was entitled 

to an additional schedule award for permanent impairment of the left upper extremity. 
3

range of motion, neck pain, and upper extremity paresthesias. Dr. Shay Alexander concluded that 

his June 12, 2009 employment injury, and resulting neck sprain, caused his cervical radiculitis 

symptoms and aggravated his cervical spinal stenosis. 

In a development letter dated July 11, 2018, OWCP related appellant’s accepted conditions, 

but informed him that the conditions of cervical radiculitis and aggravation of cervical spinal 

stenosis had not been accepted. It advised him of the type of evidence required to expand the 

acceptance of his claim and afforded him 30 days to provide the necessary evidence. 

OWCP received a progress report dated July 6, 2009, from Dr. Shay Alexander who

diagnosed closed left radius fracture and left arm and neck pain. Appellant’s physical examination 

findings were detailed. Under treatment plan, Dr. Shay Alexander referred him for a cervical 

magnetic resonance imaging (MRI) scan to rule out a herniated nucleus pulposus and a nerve 

conduction velocity and electromyogram to rule out cervical radiculitis. 

In progress reports dated July 31, 2009, Dr. Shay Alexander diagnosed limb pain, rule out 

compressive neuropathy, neck strain with possible radicular symptoms, closed left radius fracture, 

and left shoulder sprain, rule out rotator cuff tear. A physical examination revealed left cervical 

paraspinal and upper trapezius tenderness, full neck flexion and extension, Spurling maneuver 

caused pain radiating from neck to upper back and left shoulder. 

In an August 20, 2009 report, Dr. Shay Alexander diagnosed closed left radius fracture, 

left shoulder sprain, rule out rotator cuff tear, left arm pain, and neck sprain with possible radicular

symptoms. Appellant’s physical examination revealed cervical paraspinous muscle tenderness on 

the left and full range of motion with discomfort at end of range of motion. 

Dr. Shay Alexander, in a March 30, 2011 report, noted the history of appellant’s 

employment injury, summarized his medical history, and provided examination findings. She 

reported that he continued to have persistent hand, wrist, neck, and shoulder symptoms. 

Dr. Shay Alexander noted that her request for an MRI scan of the cervical spine had been denied 

because OWCP found that appellant’s cervical sprain had resolved based on a November 2, 2009 

report from Dr. Thomas J. Sabourin, a second opinion Board-certified orthopedic surgeon. She 

diagnosed cervical sprain, left wrist radial neck fracture, left carpal tunnel syndrome, and left 

shoulder impingement syndrome, and attributed appellant’s complaints of neck, left shoulder, 

elbow, and wrist pain to the June 12, 2009 employment injury. 

In a July 7, 2015 report, Dr. Dodge, a Board-certified orthopedic surgeon, noted that 

appellant was seen for neck pain and occasional pain, numbness, and tingling into his arms. 

Appellant’s history of injury and medical history were detailed. Dr. Dodge diagnosed cervical 

strain, C4-5 moderate cervical stenosis with persistence of neck pain and bilateral upper extremity 

radiculopathy and left shoulder contusion and strain with presumptive impingement syndrome 

status post left shoulder arthroscopy. He concluded that, within a reasonable degree of medical 

probability, appellant’s current symptoms appeared to be causally related to his employment 

injury.
4

By decision dated April 3, 2019, OWCP denied appellant’s request to expand acceptance 

of his claim to include the conditions of cervical radiculitis and aggravation of cervical spinal 

stenosis as causally related to the accepted June 12, 2009 employment injury. 

On April 30, 2019 appellant requested reconsideration. In support of his request, he

resubmitted reports from Dr. Shay Alexander dated July 31 and August 20, 2009, and March 30, 

2011 and a report from Dr. Dodge dated July 7, 2015. Appellant also submitted a statement dated 

July 17, 2018 in response to OWCP asserting that Dr. Shay Alexander, in her reports, addressed 

causation and that his claim should be expanded to include cervical radiculitis and aggravation of 

cervical spinal stenosis. 

By decision dated June 10, 2019, OWCP denied modification. It found the evidence 

submitted by appellant, which was duplicative, was insufficient to warrant expansion of his claim

to include cervical stenosis and cervical radiculitis. 

LEGAL PRECEDENT

An employee seeking benefits under FECA4 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

When an employee claims that a condition not accepted or approved by OWCP was due to 

an employment injury, he or she bears the burden of proof to establish that the condition is causally 

related to the employment injury.7 

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

claimed and the employment injury, an employee must submit rationalized medical evidence. 8 

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 

 

4

Supra note 2.

5 L.C., Docket No. 19-0724 (issued September 5, 2019); S.B., Docket No. 17-1779 (issued February 7, 2018); J.P.,

59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 153 (1989).

6 D.W., Docket No. 18-1139 (issued May 21, 2019); 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

S.H., Docket No. 19-1128 (issued December 2, 2019); M.M., Docket No. 19-0951 (issued October 24, 2019); 

Jaja K. Asaramo, 55 ECAB 200 (2004).

8 T.K., Docket No. 18-1239 (issued May 29, 2019); M.W., 57 ECAB 710 (2006); John D. Jackson, 55 ECAB 

465 (2004).
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explaining the nature of the relationship between the diagnosed condition and the specific 

employment factors identified by the claimant.9

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish that acceptance 

of the claim should be expanded to include the additional conditions of cervical radiculitis and 

aggravation of cervical spinal stenosis as causally related to the accepted June 12, 2009 

employment injury.

In support of expansion of the accepted conditions, appellant submitted number of medical 

reports from attending physicians, Drs. Shay Alexander and Dodge.

Reports from Dr. Shay Alexander dated June 4, 2018, July 6, July 31, and August 20, 2009

noted various diagnoses including neck sprain with possible radicular symptom, cervical 

radiculitis, and cervical spinal stenosis, but offered no opinion as to the cause of these diagnosed 

conditions. An opinion which does not address the cause of an employee’s condition is of no 

probative value on the issue of causal relationship.10 As Dr. Shay Alexander does not offer an 

opinion on causal relationship, these reports are of no probative value and, thus, insufficient to 

establish the expansion of the acceptance of appellant’s claim.

In a March 30, 2011 report, Dr. Shay Alexander diagnosed cervical strain, left wrist radial 

neck fracture, left carpal tunnel syndrome, and left shoulder impingement syndrome and she 

attributed the pain appellant experienced in his neck, left shoulder, elbow, and wrist to the June 12, 

2009 employment injury. This report did not address his alleged cervical radiculitis and cervical 

spinal stenosis conditions. The Board notes that pain is a symptom and not a compensable medical 

diagnosis.11 

Dr. Shay Alexander, in a July 6, 2018 report, diagnosed a number of conditions including 

cervical radiculitis, and cervical spinal stenosis. She opined that appellant’s June 12, 2009 

employment injury, and resulting neck sprain, aggravated his cervical spinal stenosis and caused 

his cervical radiculitis. Dr. Shay Alexander made conclusory statements that appellant’s cervical 

spinal stenosis and cervical radiculitis and pain were due to the accepted June 12, 2009 

employment injury. While she provided a conclusory opinion, she did not explain how the 

accepted employment injury had caused or aggravated additional cervical conditions. The Board 

has held that a report is of limited probative value regarding causal relationship if it does not 

contain medical rationale explaining how a given medical condition/disability was causally related 

to employment factors.12 Also, while Dr. Shay Alexander opined that appellant’s cervical stenosis 

 

9 D.S., Docket No. 18-0353 (issued February 18, 2020); T.K., id.; I.J. 59 ECAB 408 (2008); Victor J. Woodhams, 

41 ECAB 345 (1989). 

10 S.H., supra note 7; L.B., Docket No. 18-0533 (issued August27, 2018); D.K., Docket No. 17-1549 (issued 

July 6, 2018).

11 T.G., Docket No. 19-0904 (issued November 25, 2019).

12 A.L., Docket No. 18-1706 (issued May 20, 2019); Y.D., Docket No. 16-1896 (issued February 10, 2017).
6

aggravation and cervical radiculitis had been caused or aggravated by the employment injury of 

June 12, 2009, she did not provide a reasoned explanation of the biomechanical mechanism of 

injury.

13

 Her reports, therefore, are insufficient to establish expansion of the acceptance of his

claim.

In a report dated July 7, 2015, Dr. Dodge diagnosed various conditions including C4-5 

moderate cervical stenosis with persistence of neck pain and bilateral upper extremity 

radiculopathy. In the May 29, 2018 report, he diagnosed cervical radiculopathy and cervical 

spondylosis, and opined that appellant’s symptoms appeared to be causally related to the accepted 

employment injury. However, Dr. Dodge offered no opinion as to whether appellant’s cervical 

stenosis and radiculopathy were causally related to the accepted June 12, 2009 employment injury

in either report. The Board has held that medical evidence that does not offer an opinion regarding 

the cause of an employee’s condition is of no probative value on the issue of causal relationship. 14 

As Dr. Dodge did not offer an opinion regarding the cause of appellant’s cervical radiculitis and 

aggravation of cervical spinal stenosis, his reports are of no probative value and, thus, insufficient 

to establish the expansion of the acceptance of appellant’s claim.

As the medical evidence of record is insufficient to establish causal relationship, the Board 

finds that appellant has not met 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 not met his burden of proof to establish that acceptance of 

his claim should be expanded to include the additional conditions of cervical radiculitis and 

aggravation of cervical spinal stenosis as causally related to the accepted June 12, 2009 

employment injury.

 

13 P.J., Docket No. 18-1738 (issued May 17, 2019); S.F., Docket No. 18-0444 (issued October 4, 2018); E.D. 

Docket No. 16-1854 (issued March 3, 2017); L.B., Docket No. 14-1687 (issued June10, 2015).

14 Id.
7

ORDER

IT IS HEREBY ORDERED THAT June 10, 2019 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: April 21, 2020

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board