United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

B.S., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

CHARLES GEORGE VA MEDICAL CENTER, 

Asheville, NC, Employer

__________________________________________

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Docket No. 19-1854

Issued: July 30, 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

JANICE B. ASKIN, Judge

PATRICIA H. FITZGERALD, Alternate Judge

JURISDICTION

On September 6, 2019 appellant filed a timely appeal from an August 26, 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 Appellant timely requested oral argument before the Board. 20 C.F.R. § 501.5(b). By order dated July 23 2020, 

the Board exercised its discretion and denied the request, finding that the arguments on appeal could adequately be 

addressed based on the case record. Order Denying Request for Oral Argument, Docket No. 19-1854 (issued 

July 23, 2020). The Board’s Rules of Procedure provide that an appeal in which a request for oral argument is denied 

by the Board will proceed to a decision based on the case record and the pleadings submitted. 20 C.F.R. § 501.5(b).

2 5 U.S.C. § 8101 et seq.

3 The Board notes that following the August 26, 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 evidence for 

the first time on appeal. Id. 
2

ISSUE

The issue is whether appellant has met his burden of proof to establish a lumbar condition 

causally related to the accepted June 27, 2019 employment incident.

FACTUAL HISTORY

On July 15, 2019 appellant, then a 43-year-old medical instrument technician, filed a 

traumatic injury claim (Form CA-1) alleging that on June 27, 2019 he was bent over, adjusting a 

patient’s continuous positive airway pressure (CPAP) mask, when he felt a sharp pain in his lower 

back while in the performance of duty. Appellant stated that a computerized tomography (CT) 

scan displayed a herniated disc at L5. On the reverse side of the claim form, the employing 

establishment noted appellant’s date of injury as June 27, 2019, but asserted that he was not injured 

in the performance of duty as no cause of an injury was stated and he had a questionable preexisting 

condition. The employing establishment further noted that appellant did not report the incident 

until July 16, 2019, when he underwent a surgical procedure, and that he recently had issues with 

management. Appellant stopped work on July 3, 2019.

In a July 22, 2019 development letter, OWCP informed appellant that additional evidence 

was required to establish his claim. It advised him of the type of factual and medical evidence 

necessary to establish his claim. OWCP afforded appellant 30 days to submit the necessary 

evidence. 

An unsigned July 4, 2019 visit summary from a medical provider indicated that appellant 

presented with lower back pain radiating into his leg and toes that he described as burning, tingling, 

sharp, stabbing, and numbing. It related that the onset of his back pain was acute and had occurred 

in a constant pattern for the past 10 days and was now worsening. Appellant stated that he had 

difficulty with activities of daily living and that his pain was aggravated by movement. The visit 

summary noted that his pain was preceded by an incident at work. It also indicated that appellant’s

pain was located in the medial iliac crest, lumbar paraspinal, and lateral sacrum. The visit 

summary related that he was diagnosed with left side sciatica. 

A July 6, 2019 unsigned visit summary from the same provider repeated appellant’s history 

of injury and indicated that appellant presented with lower back pain, sharp left foot and leg pain 

upon movement, and achy burning upon sitting. 

A July 8, 2019 unsigned visit summary from a different medical provider indicated that 

appellant presented with worsening low back pain. It repeated his history of injury and noted that 

the previous day he received a massage and woke up in the morning with tingling in his left foot 

and calf. The visit summary stated that on Thursday appellant had tweaked his back and was now 

unable to walk well on his left leg. It additionally noted that he had not previously undergone 

lumbar surgery. 

A July 11, 2019 CT scan of appellant’s lumbar spine interpreted by Dr. Lauren Wingo, an 

emergency medicine specialist, displayed an inferior disc protrusion at L4-5 extending inferiorly 

to the level of the midportion of the L5 vertebral body, eccentric to the left, effacing the left 

subarticular recess and the thecal sac. It also showed anterior endplate spurring at L2-3. 
3

In July 11, 2019 unsigned discharge instructionsfrom an emergency department noted back 

pain and an intervertebral disc displacement of the lumbar region. The instructions identified 

appellant’s attending physician as Dr. Wingo, listed additional medications appellant was 

prescribed, and indicated that he should follow up with his primary care physician.

In a July 24, 2019 controversion letter, the employing establishment indicated that 

appellant only stated that he bent over to adjust a CPAP mask, and that his medical records did not 

mention any work-related event that could cause a disc herniation. It also related that he had 

delayed in reporting the alleged injury. 

By decision dated August 26, 2019, OWCP denied appellant’s traumatic injury claim. It 

found that the evidence of record established that the incident occurred as alleged and that a lumbar 

condition had been diagnosed. OWCP also found that the evidence of record was insufficient to 

establish causal relationship between appellant’s diagnosed condition and the accepted June 27, 

2019 employment incident. It concluded therefore that the requirements had not been met to 

establish an injury as defined by FECA.

LEGAL PRECEDENT

An employee seeking benefits under FECA4 has the burden of proof to establish the 

essential elements of his or her claim, including 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 first must be determined whether fact of injury has been established. There 

are two components involved in establishing fact of injury. First, the employee must submit 

sufficient evidence to establish that he or she actually experienced the employment incident at the 

time and place, and in the manner alleged. The second component is whether the employment 

incident caused a personal injury and this component can be established only by medical evidence.8

 

4 Supra note 2.

5 F.H., Docket No. 18-0869 (issued January 29, 2020); J.P., Docket No. 19-0129 (issued April 26, 2019); Joe D. 

Cameron, 41 ECAB 153 (1989).

6

J.H., Docket No. 18-1637 (issued January 29, 2020); James E. Chadden, Sr., 40 ECAB 312 (1988).

7 P.A., Docket No. 18-0559 (issued January 29, 2020); K.M., Docket No. 15-1660 (issued September 16, 2016); 

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

8 T.H., Docket No. 19-0599 (issued January 28, 2020); K.L., Docket No. 18-1029 (issued January 9, 2019); John J. 

Carlone, 41 ECAB 354 (1989).
4

The medical evidence required to establish causal relationship between a claimed specific 

condition and an employment incident is rationalized medical opinion evidence.9 The opinion of 

the physician must be based on a complete factual and medical background of the employee, 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 specific employment factors 

identified by the employee.10

In a case where a preexisting condition involving the same part of the body is present and 

the issue of causal relationship therefore involves aggravation, acceleration, or precipitation, the 

physician must provide a rationalized medical opinion that differentiates between the effects of the 

work-related injury or disease and the preexisting condition.11

ANALYSIS

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

condition causally related to the accepted June 27, 2019 employment incident.

In support of his claim, appellant submitted an unsigned visit summaries of July 4, 6, and 8, 

2019, from various health care providers and July 11, 2019 unsigned discharge instructions from 

a hospital. The Board has held that reports that are unsigned or bear an illegible signature lack 

proper identification and cannot be considered probative medical evidence as the author cannot be 

identified as a physician.12 Therefore, these medical records have no probative value and are 

insufficient to establish appellant’s claim.

Appellant additionally submitted a July 11, 2019 lumbar spine CT scan from Dr. Wingo 

which related a diagnosis of L4-5 inferior disc protrusion. The Board has held, however, that 

reports of diagnostic tests standing alone lack probative value as they do not provide an opinion 

on causal relationship between an employment incident and a diagnosed condition.13

As appellant has not submitted rationalized medical evidence establishing causal 

relationship between his intervertebral disc displacement of the lumbar region and the accepted 

June 27, 2019 employment incident, the Board finds that he has not met his burden of proof to 

establish his 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.

 

9 S.S., Docket No. 19-0688 (issued January 24, 2020); A.M., Docket No. 18-1748 (issued April 24, 2019); Robert G. 

Morris, 48 ECAB 238 (1996).

10 T.L., Docket No. 18-0778 (issued January 22, 2020); Victor J. Woodhams, 41 ECAB 345, 352 (1989).

11 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013); 

V.W., Docket No. 19-1537 (issued May 13, 2020); N.C., Docket No. 19-1191 (issued December 19, 2019); R.D., 

Docket No. 18-1551 (issued March 1, 2019).

12 M.A., Docket No. 19-1551 (issued April 30, 2020); T.O., Docket No. 19-1291 (issued December 11, 2019).

13 See J.M., Docket No. 17-1688 (issued December 13, 2018).
5

CONCLUSION

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

condition causally related to the accepted June 27, 2019 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the August 26, 2019 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: July 30, 2020

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board