United States Department of Labor

Employees’ Compensation Appeals Board

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N.B., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS AFFAIRS MEDICAL CENTER, 

Los Angeles, CA, Employer

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Docket No. 22-0191

Issued: May 26, 2022

Appearances: Case Submitted on the Record

Brett Elliot Blumstein, Esq., for the appellant1

Office of Solicitor, for the Director

ORDER REMANDING CASE

Before:

ALEC J. KOROMILAS, Chief Judge

JANICE B. ASKIN, Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

On November 18, 2021 appellant, through counsel, filed a timely appeal from an 

October 21, 2021 merit decision of the Office of Workers’Compensation Programs (OWCP). The 

Clerk of the Appellate Boards docketed the appeal as No. 22-0191.

On December 6, 2018 appellant, then a 56-year-old medical physician, filed a traumatic 

injury claim (Form CA-1) alleging that on November 23, 2018 she injured her upper arms, neck, 

lower back, and left leg, and sustained a skin abrasion of her upper back and lower neck when she 

fell backwards off a chair onto the floor while in the performance of duty. OWCP assigned this 

claim OWCP File No. xxxxxx860.

Appellant sustained a prior traumatic injury claim on January 9, 2017 when she slipped 

and fell on a wet floor. OWCP assigned this claim OWCP File No. xxxxxx259 and accepted it for 

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

intervertebral disc disorders with radiculopathy, lumbar region; sprain of ligaments of thoracic 

spine; sprain of other parts of lumbar spine and pelvis; and unspecified sprain of left hip. 

Appellant’s claims have not been administratively combined.

By decision dated July 30, 2019, OWCP denied appellant’s claim in OWCP File xxxxx860,

finding that she had not factually established the occurrence of the alleged November 23, 2018 

employment injury or submitted any medical evidence containing a diagnosed condition.

Thereafter, OWCP received a September 5, 2017 report from Dr. Langston T. Holly, a 

Board-certified neurosurgeon, who advised that he was treating appellant due to a January 2017 

slip and fall. Dr. Holly noted that she had previously undergone microdiscectomy surgery at L3-4 

on March 16, 2017. He provided work restrictions. 

Electrodiagnostic testing performed on December 7, 2018 yielded normal findings. An 

October 8, 2019 magnetic resonance imaging (MRI) scan of the pelvis showed abnormal T2 

hyperintensity and mild increased caliber of the left L4 nerve. 

On November 20, 2019 OWCP received a report indicating that, on December 17, 2018,

Dr. Francis M. Ferrante, a Board-certified internist and anesthesiologist, and Dr. Varun Shahi, 

who specializes in emergency medicine, evaluated appellant for left hip and leg pain. They

discussed her history of an L3-4 microdiscectomy at L3-4 in March 2017. Drs. Ferrante and Shahi 

advised that appellant had fallen off a chair recently aggravating the pain in her low back and 

experiencing “new neck pain.” They provided differential diagnoses of lumbar radiculopathy, 

complex regional pain syndrome (CRPS), plexopathy, myofascial pain, polyneuropathy, cervical 

paraspinal muscle strain, cervical fracture, and cervical radiculopathy.

In a report dated December 18, 2018, Dr. Felicia C. Yu, a Board-certified internist, and

Dr. Isabella Lai, an internist, obtained a history of appellant experiencing left leg and hip pain in 

January 2017 after a ground level fall when she tripped in a puddle of water. In March 2017,

appellant underwent a microdiscectomy at L3-4. Dr. Yu and Dr. Lai noted that she had strained 

the muscles in her neck after falling off a chair. They diagnosed muscle strain of the left thigh, 

left anterior leg pain, low back pain radiating to the left leg, acute lumbar radiculopathy, status 

post lumbar discectomy, lumbar spinal stenosis, neck strain, neck pain, and chronic left-sided low 

back pain with left sciatica.

On December 20, 2018 Dr. Ferrante discussed appellant’s complaints of pain in the left 

anterolateral hip radiating into the left groin and knee for the past 18 months. He noted that she 

had recently had “a new fall off a chair at work that has now further aggravated her lower back 

pain.” Dr. Ferrante advised that an MRI scan of the pelvis showed segmental L4 mononeuropathy. 

He related that appellant should remain off work until the next reevaluation in view of her second 

fall superimposed on her initial disabling injury. 

On January 2, 2019 Dr. Arash D. Kohanteb, Board-certified in emergency medicine,

treated appellant at the emergency department. He noted that she had experienced intermittent 

neck pain and headaches since falling off a chair and hitting her head a month earlier.

Dr. Kohanteb diagnosed neck strain and a nonintractable headache of unspecified chronicity and 

type.
3

In a report dated January 16, 2019, Dr. Justin G. Laube, a Board-certified internist, 

discussed appellant’s complaints of neck, back, and upper left leg pain. In a progress report dated 

January 29, 2019, he evaluated herfor increased back pain. Dr. Laube indicated that appellant had 

experienced a fall in January 2017.

On January 23, 2019 Dr. Ferrante evaluated appellant for neck pain with headaches and 

low back pain radiating into the left anterior thigh. He noted that she attributed her neck pain to a 

fall from a chair in November 2018. Dr. Ferrante listed the same differential diagnoses as in his 

December 17, 2018 report. He submitted similar progress reports on March 6 and 26 and 

August 6, 2019.2 

In a February 11, 2019 progress report, Dr. Yu advised that appellant had pain in her low 

back, left inner thigh, left knee, neck, and shoulder and improving headaches. She diagnosed neck 

pain, anterior left leg pain, lumbar spinal stenosis, low back pain radiating into the left leg, lumbar 

radiculopathy, chronic left-sided low back pain with left sciatica, status post lumbar discectomy, 

right trapezius muscle strain, and chronic left knee pain.

On April 9, 2019 Dr. Yu evaluated appellant for neck, back, and left leg pain. She noted 

that appellant’s symptoms of chronic left leg pain had begun a year and a half earlier after a fall

and discussed her history of a discectomy at L3-4. Dr. Yu diagnosed anterior left leg pain, sequela 

of a muscle strain of the left thigh, neck pain, stress, and chronic bilateral low back pain without 

sciatica. She provided similar progress reports dated May through November 2019. 

On August 6, 2019 Dr. Ferrante indicated that he had initially evaluated appellant on 

December 17, 2018 “when [appellant] presented after the fall from a chair at work on 

November 23, 2018 that resulted in a severe whiplash neck injury and an exacerbation of the 

symptoms of her previously lower back/left leg injury.” He related that initial findings included 

pain in the neck and upper back with muscle spasm, headaches, and loss of cervical range of 

motion. Dr. Ferrante related, “In addition, [appellant’s] recent injury has intensified her chronic 

lower back pain and the left leg radiculopathy.” He provided work restrictions. On October 8, 

2019 Dr. Ferrante recommended facet injections from C3 to C7, noting that appellant’s neck pain 

had recently increased. On September 3, 2019Dr. Laube diagnosed left leg pain, stress, neck pain, 

and a muscle strain of the left thigh. 

In a report dated February 3, 2020, Dr. Ferrante discussed appellant’s complaints of neck 

pain radiating into her upper back and chronic left hip and leg pain. He recommended cervical 

facet injections. Dr. Ferrante diagnosed lumbar radiculopathy, CRPS, plexopathy, myofascial 

pain, polyneuropathy, and cervical whiplash, cervical spondylosis, and paraspinal muscle strain.

On February 12, 2020 Dr. Jakun Ing, a Board-certified anesthesiologist, reviewed 

appellant’s history of low back and left leg radiculopathy after a January 9, 2017 fall at work. He 

related, “[Appellant’s] left leg and lower back pain from this work-related injury continues to 

persist after the surgery, and in addition, it has markedly intensified after the fall from a chair at 

work on November 23, 2018 when she sustained a severe neck whiplash injury and severe ongoing 

neck and upper back pain, muscle spasms, headaches, and markedly reduced neck mobility.”

2 The record also contains the first page of a narrative report from Dr.Ferrante dated March 26, 2019. 
4

Dr. Ing advised that a lack of reasonable accommodation at work had exacerbated her left leg pain. 

He provided work restrictions.

In an undated statement received by OWCP on February 24, 2020 appellant related that on 

November 23, 2018 she was trying to adjust her chair when she fell backward from the chair onto 

the floor. She also submitted a statement from a coworker, who found appellant on the floor next 

to her chair on November 23, 2018. Appellant described the circumstances surrounding her injury 

and noted that she had previously sustained an employment injury in January 2017 that required 

surgery. She asserted that she had sustained a whiplash injury to her neck and an exacerbation of 

her prior back injury.

On February 24, 2020 appellant, through counsel, requested reconsideration. 

By decision dated November 12, 2020, OWCP modified its July 30, 2019 decision to find 

that appellant had factually established the occurrence of the November 23, 2018 employment 

injury and submitted medical evidence containing a diagnosis. It further found, however, that the 

medical evidence was insufficient to show that she sustained a diagnosed medical condition 

causally related to the accepted November 23, 2018 employment incident.

An MRI scan of the cervical spine obtained on December 18, 2020 showed mild 

degenerative changes. An MRI scan of the thoracic spine of even date revealed a small central 

disc protrusion at “T6-C7,” and an MRI scan of the lumbar spine of even date demonstrated a 

small disc protrusion at L3-4 and severe disc degeneration and disc height loss at L4-5 and L5-S1.

On February 24, 2021 Dr. Ferrante reviewed appellant’s history of a slip and fall at work 

on January 9, 2017 and a fall from a chair at work on November 23, 2018. He advised that she 

continued to have left leg and lower back pain from the January 9, 2017 incident. Dr. Ferrante

asserted that appellant’s fall from a non-ergonomic chair at work on November 23, 2018 had 

caused a severe whiplash injury to her neck resulting in “neck and upper back pain, muscle spasms, 

headaches, reduced neck mobility, and right arm pain and numbness.” He provided work 

restrictions.

On April 9, 2021 appellant, through counsel, requested reconsideration. 

By decision dated May 7, 2021, OWCP denied modification of its November 12, 2020 

decision. 

In a report dated July 14, 2021, Dr. Ferrante again discussed appellant’s history of a 

January 9, 2017 slip and fall at work treated with surgery. He related that her fall from a chair on 

November 23, 2018 at work had aggravated her pain in her back, hip, and left leg, and caused a 

severe whiplash injury of the neck and strain/sprain of the neck, back, bilateral shoulders more on 

the right, and right arm ulnar neuropathy with paresthesia of the right arm. Dr. Ferrante discussed 

appellant’s work restrictions.

On September 15, 2021 appellant requested reconsideration. 

By decision dated October 21, 2021, OWCP denied modification of its May 7, 2021 

decision. 
5

The Board finds that the case is not in posture for decision. OWCP’s procedures provide 

that cases should be administratively combined when correct adjudication of the issues depends 

on frequent cross-referencing between files.3 For example, if a new injury case is reported for an 

employee who previously filed an injury claim for a similar condition or the same part of the body, 

doubling is required.4

In the present claim, OWCP File No. xxxxxx860, appellant alleged injuries to her upper 

arms, neck, lower back, and left leg, and a skin abrasion of her upper back and lower neck. In a 

prior claim, OWCP File No. xxxxxx259, OWCP accepted appellant’s claim for intervertebral disc 

disorders with radiculopathy, lumbar region; sprain of ligaments of thoracic spine; sprain of other 

parts of lumbar spine and pelvis, and unspecified sprain of left hip. The Board notes that both of 

appellant’s claims concern injuries to the low and mid back, and to the left lower extremity. 

However, the evidence pertaining to OWCP File No. xxxxxx259 is not part of the case record 

before the Board. For a full and fair adjudication, the case must be remanded to OWCP to 

administratively combine the current case record with OWCP File No. xxxxxx259, so it can 

consider all relevant claim files and accompanying evidence in adjudicating appellant’s current 

traumatic injury claim.5 Following this and other such further development as deemed necessary, 

OWCP shall issue a de novo decision. Accordingly,

3 Federal (FECA) Procedure Manual, Part 2 -- Claims, File Maintenance and Management, Chapter 2.400.8(c) 

(February2000).

4

Id.; M.L., Docket No. 20-1176 (issued April29, 2021); L.M., Docket No. 19-1490 (issued January 29, 2020); L.H., 

Docket No 18-1777 (issued July 2, 2019).

5

Supra note 3 at Chapter 2.400.8(c); M.M., Docket No. 21-1396 (issued April21, 2022).
6

IT IS HEREBY ORDERED THAT the October 21, 2021 decision of the Office of 

Workers’ Compensation Programs is set aside and the case is remanded for further proceedings 

consistent with this order of the Board.

Issued: May 26, 2022

Washington, 

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board