United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.V., Appellant

and

DEPARTMENT OF JUSTICE, BUREAU OF 

PRISONS, FEDERAL CORRECTIONAL 

INSTITUTION, Phoenix, AZ, Employer

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Docket No. 20-1583

Issued: August 23, 2021

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 September 3, 2020 appellant filed a timely appeal from an April 14, 2020 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.

ISSUE

The issue is whether appellant has met his burden of proof to establish greater than nine 

percent permanent impairment of his right upper extremity for which he previously received a 

schedule award.

 

1 5. U S.C. § 8101 et seq.
2

FACTUAL HISTORY

On June 29, 2018 appellant, then a 36-year-old food service administrator, filed a traumatic 

injury claim (Form CA-1) alleging that on that date he injured his right shoulder and right upper 

arm when he tripped and fell over the forks of a forklift while in the performance of duty. He

initially stopped work on June 29, 2018. On July 27, 2018 OWCP accepted appellant’s claim for 

impingement syndrome of the right shoulder. It paid him wage-loss compensation on the 

supplemental rolls commencing September 21, 2018. 

Appellant underwent OWCP-authorized right shoulder arthroscopy with debridement of 

the glenohumeral joint, posterior capsulorrhaphy, labral repair, distal clavicle resection, and 

subacromial decompression on October 1, 2018. He returned to limited-duty work on 

December 3, 2018 and full-duty work on July 16, 2019. 

On September 1, 2019 appellant filed a claim for compensation (Form CA-7) for a schedule

award. 

In support of his claim, appellant submitted progress notes, dated January 17 through 

June 13, 2019, from Dr. Gregory Evangelista, a Board-certified orthopedic surgeon, who provided 

physical examination findings and documented appellant’s right shoulder treatment following his 

right shoulder arthroscopy. 

In a July 16, 2019 report, Dr. Evangelista examined appellant’s right shoulder and found 

170 degrees of forward elevation, 45 degrees of external rotation, and internal rotation to T8. He

indicated that appellant had full rotator cuff strength and no instability or apprehension. 

Dr. Evangelista noted that appellant’s right shoulder was improving following his right shoulder 

arthroscopy. He diagnosed superior glenoid labrum lesion of the right shoulder and opined that 

appellant could return to full-duty work. Utilizing the sixth edition of the American Medical 

Association, Guides to the Evaluation of Permanent Impairment (A.M.A., Guides),2

Dr. Evangelista found that appellant had 13 percent permanent impairment of the right upper 

extremity. 

In an October 24, 2019 report, Dr. Evangelista examined appellant’s right shoulder and 

found 170 degrees of forward elevation, 45 degrees of external rotation, and internal rotation to 

T8. He again noted that appellant had full rotator cuff strength and no instability or apprehension. 

Utilizing the diagnosis-based impairment (DBI) method of the sixth edition of the A.M.A., Guides,

Dr. Evangelista identified the class of diagnosis (CDX) as a class 1 impairment for the diagnosis 

of unidirectional shoulder instability under Table 15-5, page 404. He assigned a grade modifier 

for functional history (GMFH) of 2, a grade modifier for physical examination (GMPE) of 2, and 

a grade modifier for clinical studies (GMCS) of 2 in accordance with Table 15-6, page 406 (the 

Adjustment Grid: Summary). Dr. Evangelista applied the net adjustment formula, resulting in 

movement from the default class of C to E and corresponding to 13 percent permanent impairment 

of the right upper extremity. He opined that appellant had reached maximum medical 

improvement (MMI) on July 16, 2019. 

 

2 A.M.A., Guides (6th ed. 2009).
3

On February 13, 2020 OWCP referred appellant’s case, along with a statement of accepted 

facts (SOAF), for a schedule award impairment rating with Dr. Alan J. Goodman, a Boardcertified internist, serving as the district medical adviser (DMA). In an April 1, 2020 report,

Dr. Goodman reviewed the SOAF and medical record. Utilizing the DBI method of the sixth 

edition of the A.M.A., Guides, he identified the CDX as a class 1 impairment for the diagnosis of 

unilateral shoulder instability, subluxing humeral head under Table 15-5, page 404. Dr. Goodman 

assigned a GMFH of 0, in accordance with Table 15-7, page 406, as appellant had no evidence of 

functional limitations as noted by Dr. Evangelista’s July 16 and October 24, 2019 reports. He,

therefore, disagreed with Dr. Evangelista’s assignment of a GMFH of 2. Dr. Goodman reported a 

GMPE of 0, in accordance with Table 15-8, page 408, as appellant had no physical examination 

limitations. As such, he disagreed with Dr. Evangelista’s assignment of a GMPE of 2.

Dr. Goodman noted that, a GMCS should be excluded, in accordance with Table 15-9, page 410, 

as a magnetic resonance imaging (MRI) scan was used for placement of the diagnosis within a 

specific class in the DBI grid. He calculated that appellant had a net adjustment of -2, resulting in 

movement from the default class of C to A and corresponding to nine percent permanent 

impairment of the right upper extremity. Dr. Goodman indicated that a range of motion (ROM) 

impairment was excluded from his analysis as there was insufficient data to make an assessment. 

He noted that as there was no documentation that Dr. Evangelista performed three ROM 

measurements the ROM assessment was excluded. Dr. Goodman opined that appellant had 

reached MMI on July 16, 2019. 

By decision dated April 14, 2020, OWCP granted appellant a schedule award for nine 

percent permanent impairment of the right upper extremity (right arm) based on the opinion of

Dr. Goodman, the DMA, with which the weight of the medical evidence rested. The award ran 

for 28.08 weeks for the period July 23, 2019 through February 4, 2020. 

LEGAL PRECEDENT

The schedule award provisions of FECA,3and its implementing federal regulations,4set 

forth the number of weeks of compensation payable to employees sustaining permanent 

impairment from loss, or loss of use, of scheduled members or functions of the body. However, 

FECA does not specify the manner in which the percentage of loss shall be determined. For 

consistent results and to ensure equal justice under the law for all claimants, OWCP has adopted 

the A.M.A., Guides as the uniform standard applicable to all claimants.5 As of May 1, 2009, the 

sixth edition of the A.M.A., Guides is used to calculate schedule awards.6 The Board has approved 

 

3 5 U.S.C. § 8107.

4 20 C.F.R. § 10.404.

5

Id. at § 10.404(a).

6 Federal (FECA) Procedure Manual, Part 2 -- Claims, Schedule Awards and Permanent Disability Claims, Chapter 

2.808.5(a) (7March 2017); see also id. at Chapter 3.700.2 and Exhibit 1 (January 2010).
4

the use by OWCP of the A.M.A., Guides for the purpose of determining the percentage loss of use 

of a member of the body for schedule award purposes.7

In determining impairment for the upper extremities under the sixth edition of the A.M.A., 

Guides, an evaluator must establish the appropriate diagnosis for each part of the upper extremity 

to be rated. With respect to the shoulder, the relevant portion of the arm for the present case, 

reference is made to Table 15-5 (Shoulder Regional Grid) beginning on page 401. After the CDX 

is determined from the Shoulder Regional Grid (including identification of a default grade value), 

the net adjustment formula is applied using the GMFH, GMPE, and GMCS. The net adjustment 

formula is (GMFH - CDX) + (GMPE - CDX) + (GMCS - CDX).8 Under Chapter 2.3, evaluators 

are directed to provide reasons for their impairment rating choices, including choices of diagnoses 

from regional grids and calculations of modifier scores.9

OWCP’s procedures provide that, after obtaining all necessary medical evidence, the file 

should be routed to a DMA for an opinion concerning the nature and percentage of permanent 

impairment in accordance with the A.M.A., Guides, with the DMA providing rationale for the 

percentage of impairment specified.10

ANALYSIS

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

nine percent permanent impairment of his right upper extremity for which he previously received 

a schedule award.

In support of his schedule award claim, appellant submitted an October 24, 2019 report 

from Dr. Evangelista who utilized the DBI method and identified the CDX as a class 1 impairment 

for the diagnosis of unidirectional shoulder instability under Table 15-5. Dr. Evangelista assigned 

a GMFH of 2, a GMPE of 2, and a GMCS of 2 in accordance with Table 15-6. He applied the net 

adjustment formula, resulting in movement from the default class of C to E and corresponding to 

13 percent impairment of the right upper extremity. Dr. Evangelista opined that appellant had 

reached MMI on July 16, 2019.

OWCP properly routed appellant’s case, including Dr. Evangelista’s report, to its DMA,

Dr. Goodman. In an April 1, 2020 report, the DMA utilized the DBI method and identified the 

CDX as a class 1 impairment for the diagnosis of unilateral shoulder instability, subluxing humeral 

head under Table 15-5. The DMA disagreed with Dr. Evangelista’s impairment rating because of 

his assignment of the GMFH and GMPE. He assigned a GMFH and GMPE of 0, in accordance 

 

7 See S.C., Docket No. 20-0769 (issued January 12, 2021); P.R., Docket No. 19-0022 (issued April 9, 2018); Isidoro 

Rivera, 12 ECAB 348 (1961).

8 A.M.A., Guides 405-12. Table 15-5 also provides that, if motion loss is present for a claimant with certain 

diagnosed conditions, permanent impairment may alternatively be assessed using section 15.7 (ROM impairment). 

Such a ROM rating stands alone and is not combined with a DBI rating. Id. at 401-05, 475-78.

9

Id. at 23-28.

10 See supra note 6 at Chapter 2.808.6(f) (March 2017).
5

with Table 15-7 and Table 15-8, as appellant had no functional or physical examination limitations 

as evidenced by Dr. Evangelista’s July 16 and October 24, 2019 reports and the medical record. 

The DMA noted that a GMCS should be excluded, in accordance with Table 15-9, as an MRI scan 

was used for placement of the diagnosis within a specific class in the DBI grid. He calculated that 

appellant had a net adjustment of -2, resulting in movement from the default class of C to A and 

corresponding to nine percent impairment of the right upper extremity. The DMA noted that the 

ROM rating method was not applicable as there was insufficient data to make an assessment. He

opined that appellant had reached MMI on July 16, 2019.

The Board finds that the DMA’s opinion was based on a proper factual and medical history 

and on the appropriate tables and grading schemes of the A.M.A., Guides. The DMA accurately 

applied the standards of the A.M.A., Guides to the physical examination findings of

Dr. Evangelista. He provided rationale for his impairment rating choices, including choices of 

diagnoses from regional grids and calculations of modifier scores.11 Consequently, the Board finds 

that OWCP properly accorded the weight of the medical evidence to the DMA’s April 1, 2020 

report and found nine percent permanent impairment of appellant’s right upper extremity.

12

Appellant may request a schedule award or increased schedule award at any time based on 

evidence of a new exposure or medical evidence showing progression of an employment-related 

condition resulting in permanent impairment or increased impairment.

CONCLUSION

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

nine percent permanent impairment of his right upper extremity for which he previously received 

a schedule award.

 

11 Supra note 9.

12 See V.G., Docket No. 19-1728 (issued September 2, 2020).
6

ORDER

IT IS HEREBY ORDERED THAT the April 14, 2020 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: August 23, 2021

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