United States Department of Labor

Employees’ Compensation Appeals Board

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C.W., Appellant

and

DEPARTMENT OF THE AIR FORCE, 482nd

AIRCRAFT MAINTENANCE SQUADRON, 

HOMESTEAD AIR FORCE BASE, FL, 

Employer

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Docket No. 19-0468

Issued: July 16, 2019

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 December 28, 2018 appellant filed a timely appeal from a December 6, 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.2

 

1 5 U.S.C. § 8101 et seq.

2 The Board notes that following the December 6, 2018 decision, OWCP received additional evidence. 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 

evidence for the first time on appeal. Id.
2

ISSUE

The issue is whether appellant has met his burden of proof to establish an injury causally 

related to the accepted April 10, 2018 employment incident.

FACTUAL HISTORY

On April 30, 2018 appellant, then a 40-year-old integrated avionics technician, filed a

traumatic injury claim (Form CA-1) alleging that on April 10, 2018 he injured his right mid-back 

and rib cage while in the performance of duty. He stated that he had stretched out to his left to put 

down boresight equipment when he felt a sharp pain on the right side of his mid-back/rib cage. 

Appellant further stated that the pain was extreme when trying to take a breath and when standing 

upright. On the reverse side of the claim form, the employing establishment indicated that 

appellant stopped work on April 10, 2018 and received medical treatment. It also advised that he

returned to work on April 12, 2018.

On April 10, 2018 appellant was treated in a hospital emergency department and was 

discharged the following morning. The discharge instructions indicated that he was seen by

Dr. Daniel R. Fields, an internist and emergency medicine specialist. Appellant complained of 

shortness of breath, back pain, and upper back rib pain. Dr. Fields diagnosed pleuritic chest pain. 

Appellant received prescriptions for pain medication and a muscle relaxant. He also received 

information on “nonspecific chest pain” and a note excusing him from work through 

April 12, 2018.3

In a May 4, 2018 development letter, OWCP advised appellant that additional evidence 

was required in support of his claim for compensation benefits. It explained that the medical 

evidence thus far only referenced pain, which was a symptom, not a valid medical diagnosis. 

OWCP requested that appellant submit a comprehensive narrative medical report from a qualified 

physician that included a diagnosis and an opinion, supported by medical rationale, addressing 

how the claimed employment incident caused or aggravated a medical condition. It afforded him

30 days to submit the requested medical evidence. Appellant did not respond.

By decision dated June 8, 2018, OWCP accepted that the April 10, 2018 employment 

incident occurred as alleged, but denied the claim because the medical evidence of record did not 

include a specific diagnosis in connection with the accepted employment incident. It concluded, 

therefore, that the requirements had not been met to establish an injury as defined by FECA. 

In July 2018, OWCP received additional medical records from appellant’s April 10 and11, 

2018 emergency department visit. The emergency department treatment records indicated that 

appellant complained of back pain that started earlier in the evening on April 10, 2018 while at 

work. The pain was aching, located in his right flank, and worsened with movement and breathing.

According to appellant, there were no prior episodes or additional medical history.

 

3 Appellant also provided billing statements from his April 10 and 11, 2018 emergency room visit. The billing 

records indicated that he had an electrocardiogram (ECG) performed on April 10, 2018.
3

Dr. Fields conducted a physical examination and found that appellant’s cardiovascular 

system was operating at a regular rate and rhythm, and that there was no murmur or edema. He 

also found that appellant’s back was nontender and had a normal range of motion, and that there 

was no tenderness in his chest wall. Additionally, the examination revealed that appellant’s lungs 

were clear to auscultation, his respirations were nonlabored, and breath sounds were equal. 

Appellant refused a computerized tomography scan of his chest. His ECG results were

“borderline,” revealing a lower than normal heart rate (sinus bradycardia). Dr. Fields’ final 

impression/diagnosis was back pain and pleuritic chest pain. He prescribed medication. Dr. Fields 

noted that appellant’s condition had improved and he was stable. He excused appellant from work 

for one day and advised him to return to the emergency department as needed.

On November 29, 2018 appellant requested reconsideration. He submitted an updated final 

report from Dr. Fields and resubmitted some of the initial emergency department treatment 

records.

By decision dated December 6, 2018, OWCP denied modification of its prior decision

finding that the medical evidence of record was insufficient to establish that a medical condition 

was diagnosed in connection with the accepted employment incident. 

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 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 must first be determined whether fact of injury has been established.8 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.9 Second, the employee must 

 

4 Supra note 1.

5

J.P., Docket No. 19-0129 (issued April 26, 2019); S.B., Docket No. 17-1779 (issued February 7, 2018); 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 R.R., Docket No. 19-0048 (issued April 25, 2019); L.M., Docket No. 13-1402 (issued February 7, 2014); 

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

8 R.B., Docket No. 17-2014 (issued February 14, 2019); B.F., Docket No. 09-0060 (issued March 17, 2009);

Bonnie A. Contreras, 57 ECAB 364 (2006).

9 S.F., Docket No. 18-0296 (issued July 26, 2018); D.B., 58 ECAB 464 (2007); David Apgar, 57 ECAB 137 (2005).
4

submit sufficient evidence, generally only in the form of medical evidence, to establish that the 

employment incident caused a personal injury.10 

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

relationship is rationalized medical evidence.11 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 employee.12 

Neither the mere 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.13

ANALYSIS

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

causally related to the accepted April 10, 2018 employment incident. 

Immediately following the April 10, 2018 employment incident, appellant presented to a

hospital emergency department complaining of shortness of breath, back pain, and upper back rib 

pain. Dr. Fields treated appellant in the emergency department and released him early the 

following morning with a final impression/diagnosis of back pain and pleuritic chest pain. In its 

May 4, 2018 development letter, OWCP advised appellant that “pain” was a symptom, not a valid 

diagnosis. It properly afforded him the opportunity to submit a narrative report from a qualified 

physician that included a medical diagnosis and an opinion on causal relationship.

The Board finds that the April 10 and11, 2018 emergency department treatment records, 

discharge instructions, and work excuse note do not include a valid medical diagnosis in 

connection with the accepted April 10, 2018 employment incident. As noted, Dr. Fields’ final 

impression/diagnosis was back pain and pleuritic chest pain. OWCP correctly found that pain is 

a symptom, not a specific medical diagnosis.14 It is appellant’s burden of proof to obtain and 

submit medical documentation containing a firm diagnosis, and that diagnosis must have medical 

evidence upon which it stands.15 The current record documents back and chest pain, which the 

Board has consistently held is not a compensable medical diagnosis.16 Therefore, the April 10

 

10 A.D., Docket No. 17-1855 (issued February 26, 2018); C.B., Docket No. 08-1583 (issued December 9, 2008); 

D.G., 59 ECAB 734 (2008), Bonnie A. Contreras, supra note 8.

11 L.D., Docket No. 17-1581 (issued January 23, 2018); Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).

12 L.D., id.; see also Leslie C. Moore, 52 ECAB 132 (2000); Gary L. Fowler, 45 ECAB 365 (1994).

13 Dennis M. Mascarenas, 49 ECAB 215 (1997).

14 See E.M., Docket No. 18-1599 (issued March 7, 2019); Federal (FECA) Procedure Manual, Part 2 -- Claims, 

Fact of Injury, Chapter 2.803.4a(6) (August 2012) (findings of pain or discomfort alone do not satisfy the medical 

aspect of the fact of injury medical determination).

15 E.M., Docket No. 18-1599 (issued March 7, 2019).

16 W.S., Docket No. 17-1261 (issued May 8, 2019).
5

and11, 2018 emergency department treatment records are insufficient to establish entitlement to 

FECA benefits. 

As appellant has not submitted rationalized medical evidence establishing an injury 

causally related to the accepted April 10, 2018 employment incident, he 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 has not met his burden of proof to establish an injury 

causally related to the accepted April 10, 2018 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the December 6, 2018 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: July 16, 2019

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