United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

M.H., Appellant

and

U.S. POSTAL SERVICE, CLAYTON BRANCH 

POST OFFICE, Clayton, MO, Employer

__________________________________________

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Docket No. 21-1014

Issued: July 8, 2022

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, Deputy Chief Judge

JAMES D. McGINLEY, Alternate Judge

JURISDICTION

On June 16, 2021 appellant filed a timely appeal from a May 12, 2021 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.2

ISSUES

The issues are: (1) whether appellant has met her burden of proof to expand the acceptance 

of her claim to include additional conditions as causally related to her accepted October 21, 2002 

1

5 U.S.C. § 8101 et seq.

2 The Board notes that, following the May 12, 2021 decision, appellant submitted additional evidence to OWCP.

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

employment injury; and (2) whether OWCP has abused its discretion in denying appellant’s 

request for authorization for a right side reverse shoulder replacement.

FACTUAL HISTORY

This case has previously been before the Board.3 The facts and circumstances as set forth 

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

follows. 

On October 21, 2002 appellant, a 47-year-old letter carrier, filed a traumatic injury claim 

(Form CA-1) alleging that on that date she was injured when her vehicle was struck from behind

while in the performance of duty. OWCP accepted her claim for cervical, right shoulder, right 

wrist, and lumbar strains.

4

 Appellant stopped work on October 23, 2002 and did not return.

On March 3, 2004 appellant was treated by Dr. Donald Bassman, a Board-certified 

orthopedist. Dr. Bassman noted that he performed a right knee arthroscopy and partial medial 

meniscectomy and arthroplasty of the medial tibial and medial femoral surfaces. He diagnosed 

torn medial meniscus and degenerative joint disease. 

On December 18, 2006 Dr. Bassman performed a total right knee replacement and 

diagnosed degenerative joint disease of the left knee. 

On September 26, 2008 Dr. Bassman performed a removal and excision of 

osteochondroma from the distal right femur and diagnosed osteochondroma of the dista l right 

femur medially.

Appellant came under the treatment of Dr. Jody T. Jachna, a Board-certified orthopedist, 

who on August 15, 2011 diagnosed right painful total knee arthroplasty due to lack of patella 

resurfacing and performed a right knee patellar resurfacing. On November 15, 2011 Dr. Jachna

diagnosed left knee patellar degenerative joint disease after knee arthroplasty and performed a left 

knee revision total knee arthroplasty for patellar resurfacing.

Appellant submitted a February 1, 2013 report from Dr. Jachna who treated appellant for 

swelling in the legs. She reported slipping and falling several times with subsequent pain and 

swelling below her knees. Dr. Jachna diagnosed right shoulder possible recurrent rotator cuff tear 

and bilateral knee arthroplasties with patellar resurfacing and contusions.5

3 Docket No. 13-2051 (issued February21, 2014). 

4 On March7, 2005 appellant filed an occupational disease claim for bilateral knee condition, which was accepted 

for aggravation of bilateral internal knee derangement. OWCP assigned the claim OWCP File No. xxxxxx049. It

administratively combined OWCP File Nos. xxxxxx049 and xxxxxx663 with the latter serving as the master file claim. 

5 Appellant submitted an MRI scan of the right shoulder dated February 7, 2013, which revealed a full thickness 

tear of the entirety of the supraspinatus tendon with retraction, similar to prior examination, suspected tear of the 

biceps tendon and superior anterior labrum.
3

OWCP received additional evidence. A magnetic resonance imaging (MRI) scan of the 

cervical spine dated February 12, 2018 revealed mild-to-moderate cervical spondylosis worse at 

C6-7 with moderate canal stenosis and bilateral foraminal stenosis, varying degrees of foraminal 

encroachment, and possible ischemic disease. 

On April 4, 2018 Dr. Jachna performed an open right carpal tunnel release and diagnosed 

right carpal tunnel syndrome.

Dr. Jachna subsequently treated appellant on December 10, 2018 and diagnosed right 

shoulder cuff tear arthropathy and right carpal tunnel release. She performed a steroid injection 

into the subacromial space of the right shoulder. On August 29, 2019 appellant presented with 

very limited range of motion of the right shoulder with crepitus in all planes. Dr. Jachna diagnosed 

right shoulder cuff tear arthropathy. She recommended a consultation for a reverse shoulder 

arthroplasty.

On November 6, 2019Dr. Scott G. Kaar, a Board-certified orthopedist, evaluated appellant 

for a right rotator cuff tear sustained at work years ago. He noted tenderness of the right rotator 

cuff insertion, restricted range of motion, and positive impingement sign. An x-ray of the right 

shoulder of even date revealed mild-to-moderate arthritis. Dr. Kaar diagnosed right shoulder 

chronic irreparable rotator cuff tear. He requested authorization to perform right reverse total 

shoulder arthroplasty. In a patient status report of even date, Dr. Kaar returned appellant to work 

with restrictions.

A computerized tomography (CT) scan of the right shoulder dated February 15, 2020 

revealed moderate osteoarthritis of the glenohumeral and acromioclavicular (AC) joints, superior 

subluxation of the humeral head, and supraspinatus and infraspinatus muscle atrophy consistent 

with chronic rotator cuff tear.

In development letters dated March 16 and April 21, 2020, OWCP notified appellant that 

her request for authorization of the right total shoulder replacement could not be approved. It 

indicated that the evidence was insufficient to authorize the proposed surgery, because the 

requested treatment did not appear to be medically necessary for and causally related to the 

accepted conditions. OWCP requested further evidence for consideration regarding the right 

shoulder condition.

In reports dated March 25 and May 5, 2020, Dr. Kaar treated appellant for an October 21, 

2002 work injury to the right shoulder. He diagnosed traumatic full thickness and chronic rotator 

cuff tear arthropathy originating from her right shoulder injury in 2002. Dr. Kaar indicated that 

the tear was too large, retracted, and chronic to perform a repair or joint preserving procedure. He 

opined that appellant failed comprehensive nonoperative treatment and was a candidate for reverse 

total shoulder replacement due to post-traumatic rotator cuff tear arthropathy. 

On May 6, 2020 OWCP referred appellant’s case to a DMA to determine whether appellant 

developed a right full-thickness shoulder tear/chronic rotator cuff arthropathy as a consequence of 

the work-related injury and the medical necessity of the proposed right reverse total shoulder 

replacement. It prepared a SOAF dated April 21, 2020 noting in part that appellant’s claim was 
4

accepted for cervical, right shoulder, right wrist, and lumbar strains under OWCP File No. 

xxxxxx633

On June 1, 2020 Dr. Todd Fellars, a Board-certified orthopedic surgeon serving as the 

DMA, reviewed the SOAF and the medical evidence of record and indicated that appellant 

developed a full-thickness chronic tear with rotator cuff arthropathy of the right shoulder. 

However, the Dr. Fellars concluded that appellant did not have intraarticular pathology as a result 

of her accepted work injury. Although appellant was diagnosed with a shoulder strain, he opined 

that the pain was located in the trapezius, radiating from her cervical spine, and there was no 

evidence of shoulder pathology. With regard to Dr. Kaar’s May 5, 2020 report, Dr. Fellars

disagreed with his findings and asserted that the medical records of 2002 do not support an 

intraarticular shoulder pathology rather the pain was radiating from the cervical spine toward her 

shoulder and was incorrectly diagnosed as a shoulder strain. The DMA concluded that the medical 

evidence did not support her shoulder pathology was work related.

On June 10, 2020 OWCP advised that a conflict in medical opinion evidence existed 

between Dr. Kaar, appellant’s treating physician, and Dr. Fellars, an OWCP DMA, regarding 

whether appellant developed a right full thickness shoulder tear/chronic rotator cuff arthropathy as 

a consequence of the work-related injury and the medical necessity of the proposed reverse total 

shoulder replacement.

In a report dated October 7, 2020, Dr. Kaar diagnosed work-related right shoulder 

irreparable rotator cuff and rotator cuff tear arthropathy and recommended a right reverse total 

shoulder arthroplasty. In the February 3, 2021 report, Lauren E. Smith, a physician’s assistant, 

diagnosed work-related right shoulder irreparable rotator cuff and rotator cuff tear arthropathy and 

recommended a right reverse total shoulder arthroplasty. In a February 3, 2021 work excuse note 

and patient status report, Dr. Kaar returned appellant to work with restrictions.

On February 9, 2021 OWCP referred appellant to Dr. Michael Ralph, a Board-certified 

orthopedist, to resolve the conflict in medical opinion between Dr. Kaar and Dr. Fellars. It 

prepared a SOAF dated April 21, 2020 noting in part that appellant’s claim was accepted for 

cervical, right shoulder, right wrist, and lumbar strain under OWCP File No. xxxxxxx633. 

In a March 7, 2021 report, Dr. Ralph noted his review of the SOAF, as well as the medical 

evidence of record. He opined that appellant’s accepted conditions of cervical strain, right 

shoulder strain, right wrist strain, and lumbar strain resolved decades ago. Dr. Ralph opined that 

the diagnosed full-thickness shoulder tear, chronic rotator cuff arthropathy, and right total shoulder 

replacement surgery were unrelated to the events of 2002. He advised that appellant had no injury 

or aggravation to her body of a residual nature as it related to the accepted conditions. Dr. Ralph 

indicated that appellant did not continue to have residuals of the work-related conditions and noted 

that the accepted conditions resolved shortly after the accident occurred. He further stated: “I 

would not have accepted the conditions of her right and her left knee, nor would I have 

recommended that the surgeries that were done be related to the event of 2002.” Dr. Ralph noted 

that OWCP did not comment that the knee problems were an accepted condition; however, upon 

review of the record it appeared to be an accepted claim.
5

By decision dated May 12, 2021, OWCP denied expansion of the acceptance of appellant’s 

claim, finding that the medical evidence of record was insufficient to establish that the additional 

conditions of right shoulder full-thickness tear/chronic rotator cuff arthropathy were causally 

related to the accepted October 21, 2002 employment injury. It further denied authorization for 

the reverse right shoulder replacement. OWCP noted that the referee report of Dr. Ralph

established that appellant had not developed right shoulder full-thickness tear/chronic rotator cuff 

arthropathy as a consequence of her accepted injury. It found that the weight of the medical 

opinion evidence rested with Dr. Ralph, who concluded that the requested treatment was not 

medically necessary for appellant’s accepted employment injury.

LEGAL PRECEDENT -- ISSUE 1

When 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.6

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.7 A physician’s opinion on whether there is a causal relationship 

between the diagnosed condition and the accepted employment injury must be based on a complete 

factual and medical background.8 Additionally, the physician’s opinion must be expressed in 

terms of a reasonable degree of medical certainty, and must be supported by medical rationale, 

explaining the nature of the relationship between the diagnosed condition and appellant’s specific 

employment factor(s).9

When an injury arises in the course of employment, every natural consequence that flows 

from that injury likewise arises out of the employment, unless it is the result of an independent 

intervening cause attributable to a claimant’s own intentional misconduct.10 Thus, a subsequent 

injury, be it an aggravation of the original injury or a new and distinct injury, is compensable if it 

is the direct and natural consequence of a compensable primary injury.11

FECA provides that if there is disagreement between an OWCP-designated physician and 

the employee’s physician, OWCP shall appoint a third physician who shall make an examination. 12 

For a conflict to arise the opposing physicians’ viewpoints must be of virtually equal weight and 

6

See T.F., Docket No. 17-0645 (issued August 15, 2018); JajaK. Asaramo, 55 ECAB 200 (2004).

7 E.M., Docket No. 18-1599(issued March 7, 2019); Robert G. Morris, 48 ECAB 238 (1996).

8 M.V., Docket No. 18-0884 (issued December 28, 2018); Victor J. Woodhams, 41 ECAB 345, 352 (1989).

9

Id.

10 See S.M., Docket No. 19-0397 (issued August 7, 2019); Mary Poller, 55 ECAB 483, 487 (2004); 1 Arthur Larson 

& Lex K. Larson, The Law of Workers’Compensation 10-1(2006).

11 A.T., Docket No. 18-1717 (issued May 10, 2019); Susanne W. Underwood (RandallL. Underwood), 53 ECAB 

139 (2001).

12 5 U.S.C. § 8123(a); see 20 C.F.R. § 10.321;Shirley L. Steib, 46 ECAB 309, 317 (1994).
6

rationale.13 Where OWCP has referred the case to an impartial medical examiner to resolve a 

conflict in the medical evidence, the opinion of such a specialist, if sufficiently well-reasoned and 

based upon a proper factual background, must be given special weight.14

ANALYSIS -- ISSUE 1

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

OWCP determined that a conflict in medical opinion existed between Dr. Kaar, appellant’s 

treating physician, who indicated that appellant developed a right full-thickness shoulder 

tear/chronic rotator cuff arthropathy as a consequence of the work-related injury and required 

surgery, and Dr. Fellars, a DMA, who opined that the full-thickness chronic tear with rotator cuff 

arthropathy of the right shoulder and proposed surgery were not causally related to the work injury. 

Consequently, itproperly referred appellant to Dr. Ralph, a Board-certified orthopedic surgeon for 

an impartial medical examination. The Board finds, however, that there was no conflict of medical 

opinion at the time of OWCP’s referral to Dr. Ralph. 

The April 21, 2020 SOAF provided to the DMA specifically noted that appellant’s claim 

was accepted for cervical, right shoulder, right wrist, and lumbar strain. In a report dated June 1, 

2020, the DMA, in addressing appellant’s requested conditions for expansion of the right shoulder, 

advised that the medical records of 2002 did not support an intraarticular right shoulder pathology;

rather the pain was radiating from the cervical spine toward her shoulder and was incorrectly 

diagnosed as a shoulder strain. The DMA did not accept the right shoulder strain as factual and 

work related. He concluded that appellant’s claim should not be expanded to include right fullthickness shoulder tear/chronic rotator cuff arthropathy. 

It is OWCP’s responsibility to provide a complete and proper frame of reference for a 

physician by preparing a SOAF. OWCP’s procedures dictate that when an OWCP medical 

adviser, second opinion specialist, or referee physician renders a medical opinion based on a 

SOAF, which is incomplete or inaccurate or does not use the SOAF as the framework in forming 

his or her opinion, the probative value of the opinion is seriously diminished or negated 

altogether.15 As the DMA did not use the SOAF as the framework in forming his opinion, his 

opinion is of diminished probative value.16 

Even though the report of Dr. Ralph is not entitled to the special weight afforded to the 

opinion of an impartial medical specialist resolving a conflict of medical opinion, his report can 

still be considered for its own intrinsic value17 and can still constitute the weight of the medical 

13 Darlene R. Kennedy, 57 ECAB 414, 416 (2006).

14 Gary R. Sieber, 46 ECAB 215, 225 (1994).

15 Id.;see also N.W., Docket No. 16-1890 (issued June 5, 2017).

16 Id.;see also Y.D., Docket No. 17-0461 (issued July 11, 2017).

17 See Cleopatra McDougal-Saddler, 47 ECAB 480 (1996).
7

evidence.18 However, Dr.Ralph’s report is similarly flawed, as he did not use the SOAF provided 

as the framework in forming his opinion. Dr. Ralph stated: “I would not have accepted the 

conditions of her right and her left knee, nor would I have recommended that the surgeries that 

were done be related to the event of 2002.” He did not acknowledge or understandthat appellant’s 

claim was accepted for cervical, right shoulder, right wrist and lumbar strain under OWCP File 

No. xxxxxx633 and that this claim was administratively combined with OWCP File No. 

xxxxxx049, which was accepted for aggravation of bilateral internal knee derangement. As he 

failed to rely upon a complete and accurate SOAF, his opinion is of diminished probative. 19

It is well established that proceedings under FECA are not adversarial in nature and while 

the claimant has the burden of proof to establish entitlement to compensation, OWCP shares the 

responsibility in the development of the evidence.20 Once OWCP undertook development of the 

evidence by referring appellant to a referee physician, it had the duty to secure an appropriate 

report addressing the relevant issues.21 As Dr. Ralph did not base his report on an accurate factual 

history, the case shall be remanded to OWCP for further development of the medical evidence.

On remand, OWCP shall prepare an updated SOAF and then obtain a supplemental opinion 

from Dr. Ralph. After this and other such further development as deemed necessary, OWCP shall 

issue a de novo decision.22

CONCLUSION

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

18 See Leanne E. Maynard, 43 ECAB 482 (1992); Rosa Whitfield Swain, 38 ECAB 368 (1987) (a physician was 

improperly designated as an impartial medical specialist, but his opinion nonetheless constituted the weight of the 

medical evidence). 

19 See S.T., Docket No. 18-1144 (issued August 9, 2019) (medical opinions based on an incomplete or inaccurate 

history are of limited probative value).

20 See D.M., Docket No. 19-1181 (issued December 2, 2019).

21 S.S., Docket No. 18-0397 (issued January 15, 2019); RichardF. Williams, 55 ECAB 343 (2004).

22 In light of the Board’s disposition of Issue 1, Issue 2 is rendered moot.
8

ORDER

IT IS HEREBY ORDERED THAT the May 12, 2021 decision of the Office of Workers’

Compensation Programs is set aside, and the case is remanded for further proceedings consistent 

with this decision of the Board.

Issued: July 8, 2022

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

James D. McGinley, Alternate Judge

Employees’ Compensation Appeals Board