United States Department of Labor

Employees’ Compensation Appeals Board

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R.C., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS HEALTH ADMINISTRATION, 

BALTIMORE VA MEDICAL CENTER, 

Baltimore, MD, Employer

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Docket No. 19-0897

Issued: February 17, 2021

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

CHRISTOPHER J. GODFREY, Deputy Chief Judge

JANICE B. ASKIN, Judge

JURISDICTION

On March 25, 2019 appellant filed a timely appeal from a February 5, 2019 merit decision 

of the Office of Workers’ Compensation Programs (OWCP).1 Pursuant to the Federal Employees’

 

1 Appellant timely requested oral argument pursuant to section 501.5(b) of the Board’s Rules of Procedure. 20 

C.F.R. § 501.5(b). By order dated July 21, 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. 19-0897 (issued July 21, 2020). The Board’s Rules of Procedure provide that any appeal 

in which a request for oral argument is not granted by the Board will proceed to a decision based on the case record 

and any pleadings submitted. 20 C.F.R. § 501.5(b).
2

Compensation Act2(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction to 

consider the merits of this case.3 

ISSUE

The issue is whether appellant has met her burden of proof to establish medical conditions 

causally related to the accepted February 4, 2018 employment incident.

FACTUAL HISTORY

On February 20, 2018 appellant, then a 57-year-old nurse, filed a traumatic injury claim 

(Form CA-1) alleging that on February 4, 2018 she felt a sharp pain in her back and left hip when 

bending to assist a patient from the floor while in the performance of duty, resulting in lumbar 

radiculopathy. She stopped work on February 14, 2018. In a letter dated February 26, 2018, the 

employing establishment confirmed that the claimed incident occurred as alleged, but controverted 

the claim as appellant had not established an injury.

In a report dated February 14, 2018, Dr. Jerry I. Levine, a Board-certified internist, related

appellant’s account of the February 4, 2018 employment incident. He diagnosed lumbar 

radiculopathy and prescribed medication and physical therapy.4 Dr. Levine held appellant off 

work until March 1, 2018.

In a February 28, 2018 report, Dr. Levine noted that appellant’s symptoms had improved. 

He returned her to full duty effective March 1, 2018.

By development letter dated February 27, 2018, OWCP informed appellant of the 

deficiencies of her claim. It advised her of the type of medical evidence necessary to establish her 

claim and provided a questionnaire for her completion. OWCP afforded appellant 30 days to 

respond. 

In response, appellant submitted a March 26, 2018 statement, asserting that on February 4, 

2018 she experienced sharp pain in her back, left hip, and groin when she bent down to assist a 

patient who had fallen to the floor. She indicated that she had no history of back symptoms prior 

to the incident.

By decision dated March 29, 2018, OWCP denied appellant’s traumatic injury claim. It 

accepted that the February 4, 2018 employment incident occurred as alleged, but denied her claim 

because she had failed to submit sufficient medical evidence to establish a medical diagnosis. 

 

2 5 U.S.C. § 8101 et seq. 

3 The Board notes that, following the February 5, 2019 decision, OWCP received additional evidence. Appellant 

also submitted new evidence on appeal. 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.

4 Appellant participated in physical therapy treatments from February 15 through July 10, 2018.
3

Therefore, OWCP found that the requirements had not been met to establish an injury as defined 

by FECA.

On April 25, 2018 appellant requested an oral hearing before a representative of OWCP’s 

Branch of Hearings and Review, held September 26, 2018. At the hearing, she noted that, at the 

time of the February 4, 2018 incident, the patient’s lift machine was not working in the room where 

the patient fell. Appellant was not allowed to leave the patient on the floor, so she assisted him 

into bed.

The employing establishment provided an October 22, 2018 statement, contending that 

appellant should not have lifted the patient from the floor as he expressed “a determined level of 

energy to get up.”

Appellant submitted additional evidence. Dr. Levine opined, in reports dated April 12 and 

16, 2018, that the accepted employment incident caused left-sided lumbar radiculopathy. He 

provided reports through June 20, 2018, and maintained appellant on full duty. 

Dr. John P. Collins, an osteopath Board-certified in physiatry, provided a May 3, 2018 

report, noting a history of injury and treatment. On examination he observed limited range of left 

hip motion with tenderness along the abductor tendon and over the trochanteric bursa and gluteal 

muscles. Dr. Collins reviewed an April 30, 2016 magnetic resonance imaging (MRI) scan of the 

lumbar spine, which demonstrated an L4-5 central disc protrusion with mild facet joint arthrosis 

from L3 to S1. He diagnosed a left hip strain/sprain, trochanteric bursitis, and gluteus medius 

tendinitis. Dr. Collins prescribed physical therapy. In a May 21, 2018 report, he diagnosed left 

gluteus medius calcific tendinitis.

May 3, 2018 x-rays of both hips demonstrated “[g]lobular calcific densities surrounding 

the base of the left greater trochanter, most suggestive of calcific tendinitis,” possible similar 

densities in the right greater trochanter.

In a June 11, 2018 report, Dr. Collins observed improved range of left hip motion, noting 

that appellant’s gluteus medius tendinitis was continuing to improve. He prescribed additional 

physical therapy.

By decision dated December 11, 2018 and reissued February 5, 2019,5an OWCP hearing 

representative affirmed the prior decision, finding that the medical evidence of record lacked a 

definitive diagnosis and supporting rationale. 

LEGAL PRECEDENT

An employee seeking benefits under FECA6 has the burden of proof to establish the 

essential elements of his or her claim, including the fact that the individual is an employee of the 

United States within the meaning of FECA, that the claim was timely filed within the applicable 

 

5 The December 11, 2018 decision contained typographical errors in the hearing date and the date of an OWCP 

decision. OWCP corrected these errors and reissued the decision on February 5, 2019.

6 Supra note 2.
4

time limitation of FECA,7that 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.8 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.9 

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.10 

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, place, and in the manner alleged.11 The second component is whether the employment 

incident caused a personal injury and can be established only by medical evidence.12

Rationalized medical opinion evidence is required to establish causal relationship. The 

opinion of the physician must be based on a complete factual and medical background, 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 incident.13

ANALYSIS

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

OWCP denied appellant’s traumatic injury claim, finding that the medical evidence of 

record lacked a firm diagnosis of an injury connected to the accepted February 4, 2018 employment 

incident. 

In his reports dated February 14 through May 21, 2018, Dr. Levine diagnosed left lumbar 

radiculopathy. He had treated appellant for back and left hip symptoms related to the accepted 

February 4, 2018 bending incident, and included a detailed history of injury and objective findings. 

Additionally, in May 3 and June 11, 2018 reports, Dr. Collins diagnosed a left hip strain/sprain, 

trochanteric bursitis, and gluteus medius calcific tendinitis. Dr. Collins also reviewed an April 30, 

2016 lumbar MRI scan, which demonstrated an L4-5 disc protrusion and multi-level facet joint 

 

7

J.P., Docket No. 19-0129 (issued April 26, 2019); S.B., Docket No. 17-1779 (issued February 7, 2018); Joe D. 

Cameron, 41 ECAB 153 (1989).

8

J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 

ECAB 312 (1988).

9 R.R., Docket No. 19-0048 (issued April 25, 2019); L.M., Docket No. 13-1402 (issued February 7, 2014); 

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

10 Y.D., Docket No. 19-1200 (issued April 6, 2020); S.S., Docket No. 18-1488 (issued March 11, 2019); T.H., 59 

ECAB 388 (2008).

11 M.O., Docket No. 19-1398 (issued August 13, 2020); D.W., Docket No. 19-0968 (issued October 9, 2019);

Bonnie A. Contreras, 57 ECAB 364 (2006).

12 Id.

13 J.L., Docket No. 18-1804 (issued April 12, 2019).
5

arthrosis. His diagnoses were based on an accurate history of injury and treatment, objective 

clinical findings, and diagnostic test results. The Board, therefore, finds that the diagnoses of left 

lumbar radiculopathy, left hip strain/sprain, trochanteric bursitis, and gluteus medius calcific 

tendinitis constitute medical diagnoses in connection with the accepted February 4, 2018 

employment incident.14 

As the medical evidence of record establishes diagnosed conditions, the case must be 

remanded for consideration of the medical evidence with regard to the issue of causal relationship. 

Following any further development as deemed necessary, OWCP shall issue a de novo decision.15

CONCLUSION

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

ORDER

IT IS HEREBY ORDERED THAT the February 5, 2019 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.16

Issued: February 17, 2021

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

 

14 B.C., Docket No. 20=0079 (issued October 16, 2020); M.K., Docket No. 20-0293 (issued June 22, 2020); Y.W., 

Docket No. 19-1877 (issued April 30, 2020).

15 Id.

16 Christopher J. Godfrey, Deputy Chief Judge, who participated in the preparation of the decision, was no longer 

a member of the Board after January 20, 2021.