United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

D.M., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

West Haven, CT, Employer

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Docket No. 19-1181

Issued: December 2, 2019

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

PATRICIA H. FITZGERALD, Deputy Chief Judge

JANICE B. ASKIN, Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On May 3, 2019 appellant filed a timely appeal from a February 20, 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.3

 

1 The February 20, 2019 decision denied appellant’s request to expand the acceptance of his claim to include 

myocardial infarction. The record also contains an April 23, 2019 schedule award decision, which at the time appellant 

filed the current claim was pending further review before OWCP’s Branch of Hearings and Review. See infra note 4. 

As such, the Board will not exercise jurisdiction over the April 23, 2019 schedule award decision due to its

interlocutory posture. 20 C.F.R. §§ 501.2(c)(2).

2 5 U.S.C. § 8101 et seq.

3 The Board notes that following the February 20, 2019 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 

additional evidence for the first time on appeal. Id. 
2

ISSUE

The issue is whether appellant has met his burden of proof to expand acceptance of his 

claim to include myocardial infarctions as a consequence of his November 2, 2013 employment 

injury. 

FACTUAL HISTORY

On November 2, 2013 appellant, then a 51-year-old letter carrier, filed a traumatic injury 

claim (Form CA-1) alleging that on that date he injured his elbow, back, and neck in a motor 

vehicle accident while in the performance of duty. OWCP accepted the claim for an aggravation 

of degenerative disc disease at L4-5 and L5-S1, lumbar strain, cervical strain, and right elbow 

sprain. Appellant stopped work on November 2, 2013 and returned to modified employment on 

December 16, 2013. He experienced recurrences of disability beginning June 20, 2016 and 

July 21, 2017. Appellant resumed his limited-duty employment on October 9, 2017.4 

On September 28, 2016 appellant received a lumbar epidural steroid injection to treat his 

lumbar disc disorder with radiculopathy.5

In a report dated April 26, 2017, Dr. Robin M. Brammer, an osteopath and Board-certified 

internist, advised that she had treated appellant since 2006. She noted that he had experienced two 

myocardial infarctions in October 2016, two weeks after he had received an epidural steroid 

injection to treat chronic back pain, which she noted was part of his workers’ compensation claim. 

Dr. Brammer opined that appellant’s heart attacks were caused by “adverse reactions to the 

injection.” She related, “He previously did not have heart disease. It is felt that the steroid 

injection caused or contributed to his heart attacks and would be part of his compensation claim.”

On August 23, 2017 appellant filed a claim for compensation (Form CA-7) for the period 

October 24 to December 10, 2016.

On August 25, 2017 Dr. Brammer noted that appellant had experienced two cardiac arrests 

on October 23, 2016 which had necessitated emergency surgery. In an addendum report dated 

September 5, 2017, she specified that appellant’s heart attacks had occurred on October 23, 2016. 

On November 9, 2017 Dr. Brammer noted that appellant’s second cardiopulmonary arrest 

on October 23, 2016 was “complicated by a prolonged resuscitation....” She discussed his history 

of a steroid epidural injection two weeks earlier for back pain and related, “It [is] beyond [a] 

 

4 By decision dated August 5, 2016, OWCP granted appellant a schedule award for five percent permanent 

impairment of the right upper extremity. In a decision dated June 5, 2018, it denied his request for an additional 

schedule award. By decision dated November 28, 2018, an OWCP hearing representative vacated the June 5, 2018 

decision and remanded the case for further development of the medical evidence. By decision dated April 23, 2019, 

OWCP denied appellant’s claim for an increased schedule award. On April 29, 2019 he requested an oral hearing 

before a representative of OWCP’s Branch of Hearings and Review.

5 OWCP further accepted that appellant sustained lumbar and thoracic sprains as a result of a May 12, 2007 

employment-related motor vehicle injury, assigned OWCP File No. xxxxxx833. The Board notes that this prior claim 

and the present claim have not been administratively combined. 
3

medical degree of certainty that the cardiac arrests were contributed to by the epidural steroid 

injection. In addition, [appellant] was taking high doses of ibuprofen to try to control the back 

pain, which also pose[s] known risk for cardiac events.” Dr. Brammer advised that he could no 

longer receive steroid injections or take nonsteroidal anti-inflammatory drugs (NSAIDs) that had 

controlled his pain and allowed him to work.

In a development letter dated April 16, 2018, OWCP informed appellant that the August 25 

and September 5, 2017 reports from Dr. Brammer were insufficient to establish his claim. It 

advised him of the medical and factual evidence required, including a rationalized report from a 

physician explaining the cause of his heart condition. OWCP afforded appellant 30 days to submit 

the necessary evidence.

Thereafter, appellant submitted reports regarding his October 23, 2017 hospitalization for 

myocardial infarctions and subsequent placement of two coronary artery stents. He further 

submitted the operative report from a March 17, 2017 left cardiac catheterization. 

In response to OWCP’s development letter, appellant advised that he had not experienced 

symptoms of a cardiac condition or coronary artery disease prior to his myocardial infarctions. He 

asserted that he had received an epidural injection in his back a week earlier. 

On May 15, 2018 Dr. Brammer again discussed appellant’s history of cardiopulmonary 

arrests on October 23, 2016 two weeks after an epidural steroid injection to his back. She opined 

that the epidural steroid injection as well as his use of high doses of ibuprofen for back pain 

contributed to his cardiac events.

On June 8, 2018 Dr. David I. Krohn, a Board-certified internist serving as a district medical 

adviser (DMA), opined that appellant’s risk factors of diabetes, hypertension, dyslipidemia, and 

metabolic syndrome predisposed him to coronary artery disease and caused his myocardial 

infarction. He advised that research indicated that the chronic use of oral steroids might contribute 

to coronary artery disease, but that there was “no information in the current medical knowledge 

base that a single steroid injection received two weeks before could act as a causal factor for an 

acute coronary event such as this claimant had.” Dr. Krohn noted that appellant had received 

numerous steroid injections over the years, but advised that “generally accepted medical practice 

does not consider this to be a significant risk factor for acute myocardial infarction.” He further 

indicated that studies showed a non-significant increased risk of heart events with high-dose 

ibuprofen. Dr. Krohn concluded that the epidural steroid injection and his use of ibuprofen did 

not, to a degree of medical certainty, result in his myocardial infarction. He related, “Most 

significantly, well-established medical practice supports that the risks posed by the claimant’s 

diabetes, elevated lipids, and hypertension were the overwhelming causal factors in his acute 

myocardial infarction.”

On August 15, 2018 OWCP referred appellant to Dr. Richard Cantor, Board-certified in 

internal medicine and cardiovascular disease, for a second opinion examination. It requested that

he address whether appellant’s October 23, 2016 cardiopulmonary arrests occurred as a 

consequence of the accepted November 2, 2013 employment injury and review and discuss

Dr. Brammer’s May 15, 2018 report.
4

In a report dated September 5, 2018, Dr. Cantor reviewed appellant’s history of injury and 

noted that he had undergone an epidural injection approximately two weeks before his hospital 

admission on October 23, 2016 for chest pain. He noted that appellant had experienced ventricular 

tachycardiac arrest in the emergency room which was treated with angioplasty and a stent. 

Appellant underwent a repeat cardiac catheterization after a March 2017 nuclear stress test, which 

had revealed “no significant coronary artery disease.” Dr. Cantor diagnosed status post myocardial 

infarction and coronary stenting. He disagreed with Dr. Brammer’s opinion that his myocardial 

infarction was causally related to his epidural injection. Dr. Cantor related, “It is my impression 

that it is related to his history of diabetes and hypertension. Therefore, his two cardiopulmonary 

arrest on October 23rd were related to his acute [myocardial infarction] which was not related to 

his prior epidural injection two weeks before.”

By decision dated February 20, 2019, OWCP denied appellant’s request to expand the 

acceptance of his claim to include a consequential myocardial infarction. 

LEGAL PRECEDENT

It is an accepted principle of workers’ compensation law that when the primary injury is 

shown to have arising out of and in the course of employment, every natural consequence that 

flows from the injury is deemed to arise out of the employment, unless it is the result of an 

independent, intervening cause attributable to the employee’s own intentional conduct.6 The basic 

rule is that a subsequent injury, whether an aggravation of the original injury or a new and distinct 

injury, is compensable if it is the direct and natural result of a compensable primary injury.7 With 

respect to consequential injuries, the Board has held that, where an injury is sustained as a 

consequence of an impairment residuals to an employment injury, the new or second injury, even 

though nonemployment related, is deemed, because of the chain of causation, to arise out of and 

in the course of employment, and is compensable.8

The claimant bears the burden of proof to establish a claim for a consequential injury. As 

part of this burden, he or she must present rationalized medical opinion evidence, based on a 

complete factual and medical background, establishing causal relationship. The opinion must be 

one of reasonable medical certainty and must be supported by medical rationale explaining the 

nature of the relationship of the diagnosed condition and the specific employment factors or 

employment injury.9

ANALYSIS

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

 

6 R.M., Docket No. 18-1621 (issued August 23, 2019); C.R., Docket No. 18-1285 (issued February 12, 2019).

7 K.S., Docket No. 17-1583 (issued May 10, 2018); Arthur Larson & Lex K. Larson, The Law of Workers’

Compensation § 3.05 (2014).

8 R.V., Docket No. 18-0552 (issued November 5, 2018).

9 C.D., Docket No. 18-1652 (issued June 26, 2019); K.W., Docket No. 18-0991 (issued December 11, 2018).
5

Appellant alleged that he sustained myocardial infarctions on October 23, 2016 as a 

consequence of receiving an epidural steroid injection two weeks earlier for his accepted back 

condition. In an April 26, 2017 report, Dr. Brammer attributed his two heart attacks to an adverse 

reaction from the steroid injection. On November 9, 2017 and May 15, 2018 she opined that 

appellant’s epidural steroid injection and his high use of ibuprofen for his back pain contributed to 

his cardiac events.

OWCP referred appellant to Dr. Cantor for a second opinion examination regarding 

whether he experienced cardiopulmonary arrests on October 3, 2016 as a consequence of his 

accepted employment injury. It requested that he review and discuss Dr. Brammer’s findings in 

her May 15, 2018 report.

On September 5, 2018 Dr. Cantor noted appellant’s history of an epidural steroid injection 

around two weeks before his hospitalization on October 23, 2016 for chest pain treated with 

angioplasty and a stent. He diagnosed status post myocardial infarction and coronary stenting. 

Dr. Cantor attributed appellant’s myocardial infarction to his hypertension and diabetes. He 

opined that his October 23, 2016 cardiopulmonary arrest was unrelated to his epidural injection. 

However, Dr. Cantor did not address whether appellant’s use of high dose ibuprofen for his back 

condition contributed to his myocardial infarction, as found by Dr. Brammer in her May 15, 2018 

report. 

It is well established that proceedings under FECA are not adversarial in nature, nor is 

OWCP a disinterested arbiter. While the claimant has the burden of proof to establish entitlement 

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

justice is done.10 Once it undertakes development of the record, it must do a complete job in 

procuring medical evidence that will resolve the relevant issues in the case.11 Accordingly, the 

Board finds that the case must be remanded to OWCP.12

On remand OWCP should request a supplemental report from Dr. Cantor addressing 

whether appellant’s use of high dose ibuprofen caused or contributed to his myocardial infarction. 

It should further specifically identify in its statement of accepted facts the amount of ibuprofen 

taken, whether it was diagnosed as a result of his accepted employment injury, and include the 

date of his last epidural injection prior to October 23, 2016. After this and other such further 

development as deemed necessary, OWCP shall issue a de novo decision.

CONCLUSION

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

 

10 S.S., Docket No. 18-0397 (issued January 15, 2019).

11 Id.; see also R.M., Docket No. 16-0147 (issued June 17, 2016).

12 J.T., Docket No. 18-1300 (issued March 22, 2019).
6

ORDER

IT IS HEREBY ORDERED THAT the February 20, 2019 decision of the Office of 

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

consistent with this opinion of the Board.

Issued: December 2, 2019

Washington, DC

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board