United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

R.J., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Edison, NJ, Employer

__________________________________________

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Docket No. 17-1365

Issued: May 8, 2019

Appearances: Case Submitted on the Record

Andrew M. Baron, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

PATRICIA H. FITZGERALD, Deputy Chief Judge

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On June 2, 2017 appellant, through counsel, filed a timely appeal from a December 6, 2016 

merit decision of the Office of Workers’ Compensation Programs (OWCP).2 Pursuant to the

 

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 Appellant timely requested oral argument. By order dated October 12, 2017, the Board exercised its discretion 

and denied her request as appellant’s arguments on appeal could be adequately addressed in a decision based on a 

review of the case record. Order Denying Request for Oral Argument, Docket No. 17-1365 (issued October 12, 2017).
2

Federal Employees’ Compensation Act3(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board 

has jurisdiction over the merits of this case.4

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 additional diagnosed conditions causally related to the

accepted May 24, 2011 employment injury.

FACTUAL HISTORY

This case has previously been before the Board.5 The facts and circumstances set forth in 

the prior Board decisions are incorporated herein by reference. The relevant facts are as follows. 

On May 24, 2011 appellant, then a 38-year-old mail carrier, filed a traumatic injury claim

(Form CA-1) alleging that, on that date, she fell on a wet dock while in the performance of duty, 

landing on both knees and twisting her ankle. She stopped work on the date of injury and did not 

return.

In support of her claim, appellant submitted medical evidence including a duty status report 

(Form CA-17), dated May 24, 2011, which contained an illegible diagnosis due to the injury and 

illegible signature. 

A May 24, 2011 note from a nurse practitioner indicated that appellant complained of pain 

in the left knee and medial aspect of the patella and left ankle. The nurse practitioner noted that 

appellant slipped and fell at work, injuring her knees and her left ankle. She diagnosed a sprain 

and strain of the medial collateral ligament (MCL) of the left knee, and sprain and strain of the left 

tibiofibular. 

In a May 25, 2011 report, Dr. Fauzia Hameed, a Board-certified internist, diagnosed left 

knee pain and left knee sprain/strain, and placed appellant off work. She noted that appellant 

presented with acute left knee pain of moderate-to-severe intensity and advised that appellant’s

symptoms started after she slipped on a piece of metal the prior day at work, causing her to fall

onto the floor and landing with her left knee bent under her ankle. Dr. Hameed noted that appellant 

had twisted her ankle as well. She advised that appellant felt sharp pain in her left knee, but was 

able to stand and walk. Dr. Hameed indicated that appellant was seen in the emergency room 

 

3 5 U.S.C. § 8101 et seq.

4 The Board notes that following the December 6, 2016 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. 

5 Docket No. 13-0605 (issued October 21, 2013); Order Granting Remand and Cancelling Oral Argument, Docket 

No. 14-2045 (issued April 22, 2015).
3

where she was provided with an ankle brace and crutches. She diagnosed left knee effusion and 

left knee sprain, and ruled out meniscal injury. 

By development letter dated June 3, 2011, OWCP informed appellant that the evidence 

received was insufficient to establish her claim. It advised her of the type of factual and medical 

evidence needed and provided a questionnaire for her completion. OWCP afforded appellant 30 

days to provide the requested information.

Appellant subsequently submitted additional medical evidence. A June 3, 2011 magnetic 

resonance imaging (MRI) scan of the left knee, read by Dr. Michael Kessler, a radiologist, revealed 

a highly suspicious tear of the anterior horn of the lateral meniscus, advanced chondromalacia of 

the patella, and small joint effusion with a one centimeter Baker’s cyst. 

In a June 22, 2011 report, Dr. Hameed diagnosed left knee meniscal injury/tear and knee 

sprain and strain. She completed an attending physician’s report (Form CA-20) also dated 

June 22, 2011. Dr. Hameed noted that appellant slipped and fell at work on May 24, 2011, landing

on her knees and hands. She indicated that the magnetic resonance imaging (MRI) scan revealed 

a lateral meniscus tear and diagnosed a meniscal injury. Dr. Hameed indicated that she did not

believe the condition was caused or aggravated by an employment activity. 

In reports dated June 14 and August 4, 2011, an individual with an illegible signature, 

diagnosed vertebral subluxation, complex lumbar spine, lumbar disc displacement, and meniscal 

injury and tear. Appellant was designated astotally incapacitated, and scheduled for a reevaluation 

on July 14, 2011. 

OWCP also received physical therapy notes dated June 6, 7, and 8, 2011, which diagnosed

left lateral meniscus tear, knee pain, and lumbar sprain/strain and noted treatment for right knee, 

left knee, and back conditions. 

On July 11, 2011 OWCP accepted the claim for left knee sprain and paid appellant 

compensation benefits. 

Appellant continued to submit additional medical evidence. In a July 25, 2011 attending 

physician’s report (Form CA-20), Dr. Hameed noted that appellant slipped and fell at work and 

landed on her knees and hands on May 24, 2011. She diagnosed a left lateral meniscus tear based 

on an MRI scan. Dr. Hameed indicated that she did not believe the condition was caused or 

aggravated by employment activity.

OWCP also received treatment notes from Dr. Mark Zientek, a chiropractor, dated June 8, 

14, 15, and 16, 2011. Dr. Zientek diagnosed vertebral subluxation complex, lumbar spine; and

displacement of lumbar intervertebral disc without myelopathy. He, in notes dated June 29 to 

October 6, 2011, diagnosed of vertebral subluxation complex, lumbar spine; and displacement of 

lumbar intervertebral disc with myelopathy. 

In July 27 and August 3, 2011 reports, Dr. Jeffrey M. Warshauer, a Board-certified 

orthopedic surgeon and osteopath, noted appellant’s history of injury and treatment and examined 

appellant’s left knee. He diagnosed torn left lateral meniscus with preexisting chondromalacia 

patella. Dr. Warshauer recommended surgical arthroscopy. On August 10, 2011 he completed a 
4

work capacity evaluation (Form OWCP-5c) and indicated that appellant could return to her 

regular, full-duty job.

Dr. Hameed, in reports dated August 1 and 29, and September 7, 2011, diagnosed left knee 

meniscal injury, right ankle sprain, and right knee sprain. 

OWCP also received physical therapy notes dated June 28 to October 3, 2011, regarding

treatment for left lateral meniscus tear, knee pain, and lumbar sprain/strain. The notes indicated 

that the areas treated were appellant’s right knee, left knee, neck, and back.

On August 26, 2011 OWCP referred appellant to Dr. Jeffrey Lakin, a Board-certified 

orthopedic surgeon, for a second opinion examination to determine the nature and extent of 

appellant’s accepted left knee condition. Dr. Lakin, in a September 9, 2011 report, described 

appellant’s history, noted his examination of appellant’s left hip and lower extremity, and provided 

findings. He noted that appellant underwent an MRI scan of her left knee, which revealed minimal 

chondromalacia to the patella, no meniscal tears, and intact ligaments. Dr. Lakin also advised that 

June 3, 2011 x-rays revealed a highly suspicious tear of the anterior horn of the lateral meniscus, 

advanced chondromalacia of the patella, and small joint effusion with a one centimeter Baker’s 

cyst. He indicated that appellant sustained a sprain to the left knee and that, based upon his 

evaluation, she had excellent strength and excellent motion to the knee with no disabling residuals. 

Dr. Lakin advised that appellant needed no further treatment for her left knee sprain and had no 

further disability. He also indicated that appellant did not have any concurrent nonwork-related 

disability. Dr. Lakin advised that appellant did not suffer any other additional injuries on 

May 24, 2011.6

OWCP subsequently received a September 28, 2011 report from Dr. Hameed, which

diagnosed left knee injury and knee pain. In a February 4, 2012 treatment note, Dr. Hameed noted 

that appellant was diagnosed with knee pain, chondromalacia patella, and suprapatella bursitis. 

She placed appellant off work until March 9, 2012. 

OWCP also received a February 28, 2012 chiropractic treatment note, wherein Dr. Zientek 

diagnosed exacerbation of spinal condition, lumbosacral muscle spasms, sacroiliac joint 

dysfunction, and vertebral subluxation complex (VSC) of the lumbar spine. 

By decision dated March 31, 2014, OWCP terminated appellant’s medical benefits for her 

accepted left knee condition, effective that date. 

Appellant appealed to the Board. By order dated April 22, 2015, the Board granted the 

Director of OWCP’s motion to remand and cancel oral argument. The Board accordingly set aside 

the July 25, 2012 decision and remanded the case so that OWCP could seek clarification from

 

6 By decision February 3, 2012, OWCP terminated appellant’s medical benefits, effective February 6, 2012, on the 

grounds that she had no continuing residuals of her accepted left knee injury. By decision dated July 25, 2012, an 

OWCP hearing representative affirmed the February 3, 2012 decision. Appellant appealed to the Board. By decision 

dated October 21, 2013, the Board reversed the July 25, 2012 decision and remanded the case, finding that Dr. Lakin’s 

second opinion was insufficiently rationalized. On remand OWCP further developed the claim by referring appellant 

to Dr. William Oppenheim, a Board-certified orthopedic surgeon for a new second opinion examination. 

Dr. Oppenheim issued a January 28, 2014 report opining that the employment-related injury had ceased.
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Dr. Oppenheim regarding appellant’s ability to work. The Board further ordered OWCP to allow 

appellant an opportunity to submit relevant evidence if she claimed other conditions as causally 

related to the accepted employment injury.7

On remand OWCP requested that appellant submit relevant evidence regarding any 

additional conditions that she believed were causally related to the accepted employment injury of

May 24, 2011. It also requested a second opinion examination with Dr. Donald Heitman, a Boardcertified orthopedic surgeon to determine whether appellant continued to have residuals or 

disability due to the accepted May 24, 2011 employment injury.

In a December 7, 2015 report, Dr. Heitman noted appellant’s history of injury and 

treatment, and provided examination findings. He noted that appellant is status post left anterior 

cruciate ligament reconstruction and that she has some subtle instability in the left knee and does 

suffer from disabling residuals of the accepted left knee condition. Dr. Heitman recommended no 

further treatment and determined that appellant could return to work eight hours per day with 

limited standing. He further opined that the acceptance of the claim should not be expanded to 

include any additional conditions.

Appellant subsequently submitted additional evidence. OWCP received an August 17, 

2015 duty status report (Form CA-17) with an illegible signature and diagnoses. 

In a series of reports dated August 4, 2014 through February 6, 2015, Dr. Jennifer Gyi, 

Board-certified in physical medicine and rehabilitation, diagnosed multiple joint and muscle pains,

low back pain, right ankle and hand swelling, lumbar facet syndrome, possible myofascial pain, 

and rheumatoid arthritis. 

A December 13, 2013 MRI scan of the lumbar spine read by Dr. Specktor revealed: 

anatomic alignment of the lumbar spine with no evidence of fracture or conus compression; mild 

multilevel degenerative disc disease and mild bilateral facet joint hypertrophy at L3-4, L4-5, and 

L5-Sl; and a small right paracentral disc herniation, protrusion type with annular fibrosis fissure, 

without spinal canal stenosis or nerve compression. 

In an August 17, 2015 report, Dr. Jackson Okoya, a Board-certified internist, opined that 

appellant was disabled and restricted her to limited-duty work to include no more than one hour 

of sitting or standing; and no walking, climbing, kneeling, bending, stooping, reaching above 

shoulder, or driving a vehicle.

In May 2016, OWCP referred appellant for another second opinion examination with

Dr. Heitman, specifically to determine whether the acceptance of the claim should be expanded to 

include right knee and back conditions. 

In a June 6, 2016 report, Dr. Heitman advised that appellant’s chief complaint was left knee 

pain. His findings included: that appellant walked without a limp; that she had medial and lateral 

femoral tibial joint line tenderness; and lateral and medial patellofemoral joint line tenderness. 

Dr. Heitman also found tenderness over the bursal region over the site of the tibial tunnel and full 

 

7 Order Granting Remand and Cancelling Oral Argument, Docket No. 14-2045 (issued April 22, 2015).
6

range of motion of the knee. He opined that the clinical findings supported the accepted condition 

of a sprained left knee and leg. Dr. Heitman explained that appellant had an element of posttraumatic arthrosis in the left knee, which was related to her employment-related injury and was 

delaying her recovery. He opined that appellant’s post-traumatic arthrosis developed over time 

due to the work-related conditions and was permanent. Dr. Heitman noted that she would not be 

able to stand long enough to adequately perform her duties as a mail carrier. He opined that 

appellant could perform sedentary positions and was not totally disabled from work.

With regard to the right knee and back, Dr. Heitman explained that appellant had no 

complaints of pain in those parts of her body. He opined that there was no causal relationship 

between the right knee or back and the employment injury; and the acceptance of the claim “should 

not be expanded.”

By letter dated August 24, 2016, OWCP requested clarification from Dr. Heitman 

regarding whether appellant was disabled from work since the May 24, 2011 injury due to the 

accepted condition. 

In a September 2, 2016 supplemental report, Dr. Heitman explained that appellant was not 

disabled since May 24, 2011. Based upon the history provided and records reviewed, he found 

that appellant was able to work full duty until her December 7, 2012 left knee surgery, and 

following the surgery, she would have been able to return to work with restrictions. Dr. Heitman

explained that it was not uncommon to have subtle instability as seen on examination today, a few 

years after that type of procedure. He noted that his restrictions would be from the December 7, 

2012 until the present.

By decision dated December 6, 2016, OWCP denied expansion of the acceptance of 

appellant’s claim to include the additional conditions of right knee sprain, lumbar facet syndrome, 

vertebral subluxation complex lumbar spine, displacement of lumbar intervertebral disc without 

myelopathy, and left or right ankle sprain. It found that the medical evidence of record was 

insufficient to establish causal relationship between those diagnosed conditions and the accepted 

employment injury.

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.8 To establish causal relationship between the condition, 

as well as any attendant disability claimed and the employment event or incident, the claimant

must submit rationalized medical opinion evidence based on a complete factual and medical 

background, supporting such causal relationship.9 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 

 

8 See V.B., Docket No. 12-0599 (issued October 2, 2012); Jaja K. Asaramo, 55 ECAB 200 (2004).

9 See M.W., 57 ECAB 710 (2006); John D. Jackson, 55 ECAB 465 (2004).
7

between the diagnosed condition and the specific employment factors identified by the claimant.10 

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

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

physician’s opinion.11

ANALYSIS

The Board finds that appellant has not established that the acceptance of her claim should 

be expanded to include the additional conditions of lumbar facet syndrome, vertebral subluxation 

complex lumbar spine, displacement of lumbar intervertebral disc without myelopathy, right knee 

sprain, and left or right ankle sprain.

In his second opinion reports, Dr. Heitman described the May 24, 2011 employment injury 

and discussed his findings. In his reports, he was clear in concluding that appellant’s additional 

conditions were not causally related to the accepted injury. Dr. Heitman explained that there was 

no objective evidence to link appellant’s claimed right knee and back injuries to her accepted 

May 24, 2011 employment injury. As his reports were sufficiently rationalized and based on an 

accurate factual history, Dr. Heitman’s opinion constitutes the weight of the medical evidence.

Dr. Hameed initially diagnosed left knee pain, left knee sprain and strain and placed her 

off work. In a May 25, 2011 report, she noted that appellant presented with acute knee pain of 

moderate to severe intensity after a fall and diagnosed knee effusion, knee sprain. In a subsequent

attending physician’s report (Form CA-20), Dr. Hameed indicated that the MRI scan revealed a 

lateral meniscus tear and diagnosed a meniscal injury. She indicated that she did not believe the 

condition was caused or aggravated by an employment activity. 

In reports dated August 1 and 29, and September 7, 2011, Dr. Hameed diagnosed right 

ankle sprain, right knee sprain, and various pains. In a February 4, 2012 treatment note, she noted 

that appellant was diagnosed with knee pain, chondromalacia patella and suprapatella bursitis. 

However, Dr. Hameed did not explain how these diagnoses were causally related to the work injury

of May 24, 2011. While the medical opinion of a physician supporting causal relationship does 

not have to reduce the cause or etiology of a disease or condition to an absolute certainty, neither 

can such opinion be speculative or equivocal. The opinion of a physician supporting causal 

relationship must be one of reasonable medical certainty that the condition for which compensation 

is claimed is causally related to federal employment and such relationship must be supported with 

affirmative evidence, explained by medical rationale and be based upon a complete and accurate 

medical and factual background of the claimant.12 Without further explanation or rationale, these 

reports are insufficient to establish that the additional conditions are causally related to the 

accepted employment injury.

 

10 See John W. Montoya, 54 ECAB 306 (2003).

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

12 Samuel Senkow, 50 ECAB 370 (1999); Thomas A. Faber, 50 ECAB 566 (1999).
8

The record contains physical therapy notes dated June 6, 7, 8, 28, and October 3, 2011. 

Additionally, the record contains a May 24, 2011 note from a nurse practitioner, who indicated 

that appellant complained of pain in the left knee and medical aspect of the patella and left ankle. 

Physical therapists and nurse practitioners, however, are not considered physicians under FECA. 

Thus, they are not competent to render a medical opinion and their reports are of no probative 

value.

13

 

OWCP also received diagnostic testing reports dated June 3, 2011, December 13, 2013, 

and August 14, 2014. However, the Board has held that diagnostic studies lack probative value as 

they do not address whether the employment injury caused any of the diagnosed conditions.

14

Appellant submitted chiropractic reports from Dr. Zientek from June 8 to October 6, 2011

and February 28, 2012. Section 8101(2) of FECA provides that the term physician includes 

chiropractors only to the extent that their reimbursable services are limited to treatment consisting 

of manual manipulation of the spine to correct a subluxation as demonstrated by x-ray to exist.15 

Dr. Zientek did not diagnose a subluxation based on x-rays.16 In the absence of a diagnosis of 

subluxation based on x-rays, he is not considered a physician under FECA. Therefore, 

Dr. Zientek’s chiropractic reports are of no probative value.17

The record also contains reports from an individual with an illegible signature dated 

June 14 and August 4, 2011, and August 17, 2015. It is unclear if they were from a physician. 

The Board has held, a report that is unsigned or bears an illegible signature lacks proper 

identification and cannot be considered probative medical evidence.18

OWCP also received a July 27 and August 3, 2011 report from Dr. Warshauer, who 

diagnosed a torn lateral meniscus with preexisting chondromalacia patella and requested surgery. 

The Board notes these reports merely contained a diagnosis. Medical evidence which does not 

 

13

 See 5 U.S.C. § 8101(2) (this subsection defines a physician as surgeons, podiatrists, dentists, clinical 

psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined 

by state law); see also 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); S.S., Docket No. 18-0950 

(issued October 23, 2018) (physical therapists are not considered physicians under FECA); S.J., Docket No. 17-0783, 

n.2 (issued April 9, 2018) (nurse practitioners are not considered physicians under FECA); Charley V.B. Harley, 2 

ECAB 208, 211 (1949) (a medical issue such as causal relationship can only be resolved through the submission of 

probative medical evidence from a physician).

14 See L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., Docket No. 17-1549 (issued July 6, 2018).

15 5 U.S.C. § 8101(2). 

16 OWCP’s implementing federal regulations define subluxation to mean an incomplete dislocation, off-centering, 

misalignment, fixation or abnormal spacing of the vertebrae which must be demonstrated on x-ray. See 20 C.F.R. 

§ 10.5(bb). 

17 Michelle Salazar, 54 ECAB 523 (2003). 

18 See A.P., Docket No. 18-0238 (issued July 20, 2018).
9

offer an opinion regarding the cause of an employee’s condition is of no probative value on the 

issue of causal relationship.19

Dr. Gyi provided a report dated October 27, 2014, in which she diagnosed “multiple joint 

and muscle pains.” In a May 19, 2014 report, she diagnosed “lumbar facet syndrome” and 

“possible myofascial pain” and in her August 4, 2014 report, she diagnosed “lumbar facet 

syndrome” and “rheumatoid arthritis” in her August 4, 2014 report. Because Dr. Gyi did not offer 

an opinion on causal relationship between these conditions and the accepted May 24, 2011 

employment injury, her opinion is of no probative value.20 In her February 6, 2015 report, she 

diagnosed “low back pain,” right ankle and right hand swelling. However, the Board has held pain

is a symptom, not a diagnosis and therefore does not constitute the basis for the payment of 

compensation.21

In an August 17, 2015 report, Dr. Okoya merely opined that appellant was disabled and 

restricted her to limited-duty work. He did not provide a diagnosis or offer an opinion as to 

additional conditions that were related to the May 24, 2011 injury at work. Thus, Dr. Okoya’s

opinion is of no probative value on the issue of causal relationship.22

As Dr. Heitman’s opinion carries the weight of the medical evidence, the Board finds that 

appellant has not met her burden of proof.

On appeal counsel argues that OWCP continued to stall and send appellant to physicians 

who issued unilateral opinions contrary to her medical condition. However, as explained above, 

the Board finds that Dr. Heitman’s opinion carries the weight of the medical evidence. Appellant 

has not met her 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 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 the additional diagnosed conditions of

lumbar facet syndrome, right knee sprain, and right ankle sprain were causally related to the 

May 24, 2011 employment injury.

 

19 See L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., Docket No. 17-1549 (issued July 6, 2018).

20 Id.

21 John L. Clark, 32 ECAB 1618 (1981).

22 L.B. supra note 19.
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ORDER

IT IS HEREBY ORDERED THAT the December 6, 2016 decision of the Office of 

Workers’ Compensation Programs is affirmed.

23

Issued: May 8, 2019

Washington, DC

Patricia H. Fitzgerald, Deputy 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

 

23 The Board notes that he employing establishment issued appellant a signed authorization for examination and/or 

treatment (Form CA-16). The Board has held that where an employing establishment properly executes a Form CA16, which authorizes medical treatment as a result of an employee’s claim for an employment-related injury, it creates 

a contractual obligation which does not involve the employee directly to pay the cost of the examination or treatment 

regardless of the action taken on the claim. See 20 C.F.R. §§ 10.300, 10.304; R.W., Docket No. 18-0894 (issued 

December 4, 2018).