United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

H.T., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

HUNTER HOLMES MCGUIRE VETERANS 

AFFAIRS MEDICAL CENTER, Richmond, VA, 

Employer

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Docket No. 20-1238

Issued: July 12, 2021

Appearances: Case Submitted on the Record

Alan J. Shapiro, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

JANICE B. ASKIN, Judge

PATRICIA H. FITZGERALD, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On June 3, 2020 appellant, through counsel, filed a timely appeal from an April 27, 2020 

merit decision of the Office of Workers’ Compensation Programs (OWCP). 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

In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for legal 

or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. § 501.9(e). 

No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An attorney or 

representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject to fine or 

imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation.

2 5 U.S.C. § 8101 et seq.

3 The Board notes that, following the April 27, 2020 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 her burden of proof to establish that the acceptance 

of her claim should be expanded to include complex regional pain syndrome (CRPS).

FACTUAL HISTORY

This case has previously been before the Board.4 The facts and circumstances of the case 

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

are as follows. 

On January 20, 2010 appellant, then a 51-year-old laundry worker, filed an occupational 

disease claim (Form CA-2) alleging that she developed bilateral upper extremity symptoms while 

in the performance of duty. She explained that she transported heavy carts throughout the entire 

hospital several times a day. Appellant noted that she first became aware of her condition on 

June 1, 2009 and realized its relation to her federal employment on January 19, 2010. OWCP 

accepted the claim for bilateral carpal tunnel syndrome. Appellant underwent OWCP-authorized 

right carpal tunnel release on September 9, 2013 and left carpal tunnel release on October 7, 2013. 

She returned to work for approximately three weeks in November 2013. OWCP paid 

compensation for temporary total disability on the supplemental rolls as of November 12, 2013

and on the periodic rolls as of February 9, 2014.

In a May 28, 2014 report, Dr. Jawad Bhatti, a Board-certified physiatrist, first diagnosed 

appellant with CRPS. He also started prescribing medication for her chronic pain. In attending 

physician’s reports (Form CA-20) dated May 28, 2014 through December 21, 2017, Dr. Bhatti 

diagnosed CRPS Type 2, which he opined by checking a box marked “Yes” was caused or 

aggravated by the employment activity. Corresponding progress notes were provided which 

diagnosed reflex sympathetic dystrophy of the upper limb. Dr. Bhatti also continued to prescribe 

narcotic medications. 

In a July 7, 2015 electromyography (EMG) report, Dr. Karen Steidle, a Board-certified 

physiatrist, compared appellant’s current EMG against her previous EMG of August 8, 2013. She 

found evidence of mild right sensory median neuropathy at the wrist without associated 

denervation, appeared approved since prior study, evidence of mild left sensory median 

neuropathy at the wrist without associated denervation, unchanged since prior study, and new 

evidence of borderline to very mild bilateral ulnar demyelinative slowing at the elbows without 

any sign of axonal loss. 

In a March 19, 2016 report, Dr. James Schwartz, an orthopedic surgeon and second opinion 

physician, reviewed a statement of accepted facts (SOAF) and noted examination findings. In 

relevant part, he opined that appellant’s “physical examination is far too bizarre to relate to carpal 

tunnel syndrome or to [CRPS] II” and opined that her marked nonphysiologic pain behavior was 

not “CRPS II.” Dr. Schwartz indicated that she had nonphysiologic behavior and her examination 

was not explicable by any known pathologic condition. 

In reports dated September 7, 2017 and February 15, 2018, Dr. Bhatti upgraded appellant’s 

diagnosis to CRPS I of the bilateral upper limb and possible CRPS Type 2 secondary to carpal 

 

4 Order Dismissing Appeal, Docket No. 19-0944 (issued December 18, 2019); Docket No. 18-0979 (issued 

February 4, 2019).
3

tunnel surgery. He indicated that she experienced constant, excessive, severe pain with little or no 

stimuli, and her bilateral surgical release did not resolve her symptoms, noting that the July 7, 2015 

EMG study and October 21, 2016 nerve conduction velocity (NCV) studies showed severe 

neuropathy in bilateral median nerves in both wrists and arms after surgery. Dr. Bhatti indicated 

that the above diagnostic tests, blood tests, and Sudomotor Axon Reflex Tests confirmed the 

diagnosis. He indicated that the criteria to determine CRPS was based on appellant’s history, 

physical examination, and nerve conduction blocks. Dr. Bhatti also noted that she had objective 

positive findings for pain on palpation, a withdrawal response and abnormal NCV testing, which 

revealed severe C8 nerve injury. 

On March 29, 2019 OWCP referred appellant, along with a March 14, 2019 SOAF, the 

medical record, and a series of questions to Dr. Norman Marcus, a Board-certified orthopedic 

surgeon, for a second opinion evaluation. The SOAF indicated that the case was accepted for 

bilateral carpal tunnel syndrome. The questions, in pertinent part, included the causal relation of 

the CRPS. 

In an April 25, 2019 report, Dr. Marcus noted his review of the case record and physical 

examination findings. He opined that appellant’s pain did not meet the criteria of carpal tunnel 

syndrome and never did. Dr. Marcus further opined that he was unable to ascertain whether she

has a regional pain syndrome or was “acting out” those complaints. 

In May 23, June 21, and July 23, 2019 CA-20 forms, Rebecca Beecroft, a nurse 

practitioner, opined by checking a box marked “Yes” that appellant’s CRPS Type 2 was caused or 

aggravated by the employment activity. 

In an August 23, 2019 Form CA-20, Dr. Bhatti continued to opine with a check box marked

“Yes” that appellant’s CRPS Type 2 was caused or aggravated by the employment activity. 

On September 18, 2019 OWCP referred appellant to Dr. Chester DiLallo, a Board-certified 

orthopedic surgeon, for a second opinion examination. A copy of the March 14, 2019 SOAF and 

a list of questions were provided. 

Ms. Beecroft continued to opine, in a September 23, 2019 Form CA-20, that appellant’s 

CRPS Type 2 was caused or aggravated by the employment activity. 

In a September 24, 2019 report, Dr. DiLallo noted his review of the medical records and 

the SOAF. He noted appellant’s complaints and presented examination findings of the bilateral 

upper extremities, noting questionable effort or little resistance in response to testing. Dr. DiLallo 

noted that she had worked just one day since the carpal tunnel surgeries and reported little 

improvement in symptoms. He opined that the subjective complaints did not correspond with the 

objective examination findings. Dr. DiLallo noted that most of the objective examination findings 

were tempered by the fact that appellant’s interpretation of sensations was subjective. Subjective 

findings included principally tingling in both hands, and pain radiating from the hands to the 

shoulders, left worse than right. Objective findings were restricted to the presence of intact 

reflexes. Appellant failed to identify two-point discrimination in any area of either hand, but had 

good capillary refill. The absence of sweating and sudomotor changes was significant. 

Dr. DiLallo opined that the accepted diagnosis of bilateral carpal tunnel syndrome had not 

resolved, noting that the objective findings were limited to the EMG and NCV studies as all other 

findings on physical examination were nonphysiologic. He opined that appellant’s condition had 

reached maximum medical improvement and restrictions/limitations were medically warranted. 

Dr. DiLallo further opined that there was a need for further medical treatment, including intense 
4

psychological evaluation and testing and referral to a neurologist and/or rheumatologist, because 

of the duration of symptoms, the character of the symptoms, and her dependence on opioids. 

Additionally, he opined that there was no evidence of CRPS on evaluation or on history and thus 

the question as to whether or not it was due to the work injury was moot. Dr. DiLallo indicated 

that the appellation of CRPS supplied by appellant’s treating physicians had no basis in fact. 

By decision dated October 8, 2019, OWCP denied the expansion of appellant’s claim to 

include the additional condition of CRPS. It found that the weight of the medical evidence rested 

with Dr. DiLallo’s September 24, 2019 opinion.

On October 28, 2019 appellant requested an oral hearing before a representative of 

OWCP’s Branch of Hearings and Review, held March 5, 2020.

OWCP continued to receive additional evidence. In CA-20 forms dated October 23 and 

November 22, 2019, Ms. Beecroft continued to opine that appellant’s CRPS Type 2 was caused or 

aggravated by the employment activity. 

In a November 27, 2019 prescription note, Dr. Bhatti diagnosed CRPS Type 2 and referred 

appellant for a functional capacity evaluation. 

Ms. Beecroft, in January 23, February 21, and March 23, 2020 Forms CA-20, and

Dr. Bhatti, in an April 20, 2020 Form CA-20, continued to opine that appellant’s CRPS Type 2 

was caused or aggravated by her employment activity. 

By decision dated April 27, 2020, the hearing representative affirmed OWCP’s October 8, 

2019 decision. 

LEGAL PRECEDENT

Where 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.5

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

relationship is rationalized medical evidence.6 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.7 

The weight of medical evidence is determined by its reliability, its probative value, its convincing 

 

5 See L.C., Docket No. 20-0866 (issued February 26, 2021); T.F., Docket No. 17-0645 (issued August 15, 2018); 

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

6 See S.L., Docket No. 19-0603 (issued January 28, 2020); S.A., Docket No. 18-0399 (issued October 16, 2018); 

Kenneth R. Love, 50 ECAB 276 (1999).

7 See J.T., Docket No. 19-1723 (issued August 24, 2020); P.M., Docket No. 18-0287 (issued October 11, 2018); 

John W. Montoya, 54 ECAB 306 (2003).
5

quality, the care of analysis manifested and the medical rationale expressed in support of the 

physician’s opinion.8

ANALYSIS

The Board finds that appellant has not met her burden of proof to establish that the 

acceptance of her claim should be expanded to include CRPS.

On May 28, 2014 Dr. Bhatti diagnosed CRPS, but offered no opinion on causal 

relationship. 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.9 

This report is therefore insufficient to establish expansion of the claim.

In Form CA-20 reports dated May 28, 2014 through April 21, 2020, Dr. Bhatti opined, by 

checking a box marked “Yes” that appellant’s CRPS Type 2 was caused or aggravated by the 

employment activity, but offered no medial rationale to support his opinion. 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 related to employment 

factors.10 These reports are therefore of limited probative value and insufficient to establish

expansion of the claim.

11

While Dr. Bhatti offered some objective findings to support a diagnosis of CRPS 1 and 

possible CRPS Type 2 secondary to carpal tunnel surgery in his reports dated September 7, 2017 

and February 15, 2018, no medical rationale was provided to support his causation opinion. The 

Board has held that medical opinion evidence should offer a medically-sound explanation of how 

the specific employment factors physiologically caused the injury.12 Thus, these reports are also

insufficient to establish expansion of the claim.

OWCP also received a number of reports wherein Ms. Beecroft, a nurse practitioner,

opined that appellant’s CRPS Type 2 was caused or aggravated by the employment activity. The 

Board has held that medical reports signed solely by nurse practitioners are of no probative value 

as nurse practitioners are not considered physicians as defined under FECA.13 These reports are

therefore insufficient to establish expansion of appellant’s claim.

 

8 See H.H., Docket No. 16-0897 (issued September 21, 2016); James Mack, 43 ECAB 321 (1991).

9 See D.W., Docket No. 18-1139 (issued May 21, 2019); L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., 

Docket No. 17-1549 (issued July 6, 2018).

10 See D.W., id.; Y.D., Docket No. 16-1896 (issued February 10, 2017).

11 Id.

12 See H.A., Docket No. 18-1466 (issued August 23, 2019); L.R., Docket No. 16-0736 (issued September 2, 2016).

13 Section 8101(2) of FECA provides that physician “includes surgeons, podiatrists, dentists, clinical psychologists, 

optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law.” 

5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t). See also Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal 

Relationship, Chapter 2.805.3a(1) (January 2013); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006) (lay individuals 

such as physician assistants, nurses, and physical therapists are not competent to render a medical opinion under 

FECA). See M.C., Docket No. 19-1074 (issued June 12, 2020); S.L., Docket No. 19-0607 (issued January 28, 2020) 

(nurse practitioners are not considered physicians under FECA).
6

In a September 24, 2019 report, Dr. DiLallo, a second opinion physician, affirmed the 

diagnosis of bilateral carpal tunnel syndrome and unequivocally rejected the diagnosis of CRPS. 

He noted that there was no evidence of CRPS on evaluation or on history and explained the absence 

of CRPS in arriving at his conclusion. The Board finds that Dr. DiLallo’s opinion, which is well 

rationalized and based upon a proper factual and medical history, constitutes the weight of the 

medical evidence on the issue of whether appellant’s CRPS is causally related to the accepted 

June 1, 2009 employment injury.14 

As the medical evidence of record is insufficient to establish that appellant’s CRPS is 

causally related to her accepted June 1, 2009 employment injury, the Board finds that she has not 

met her burden of proof to establish expansion of the acceptance of her claim.

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 and 20 C.F.R. 

§§ 10.605 through 10.607.

CONCLUSION

The Board finds that appellant has not met her burden of proof to establish that the 

acceptance of her claim should be expanded to include CRPS.

 

14 See L.C., Docket No. 18-1759 (issued June 26, 2019); D.M., Docket No. 17-1052 (issued January 24, 2019).
7

ORDER

IT IS HEREBY ORDERED THAT the April 27, 2020 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: July 12, 2021

Washington, DC

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board