Opinion ID: 6536841
Heading Depth: 3
Heading Rank: 2

Heading: Evidence related to the date of medical stability

Text: The Commission concluded that Tobar failed to prove by a preponderance of the evidence that her disability continued past the time of Dr. Youngblood's EME, because the medical evidence to date demonstrates that the work injury resolved without the need for ongoing medical treatment and because the evidence is that she has been medically stable for some time. The Commission noted that Tobar returned to Wilson after the EME but that, despite Wilson's referral for physical therapy, Tobar did not seek medical treatment, including physical therapy[,] for the next two years. But this observation overlooks critical facts. First, the Commission, like the Board, failed to mention the physical therapy provider's explanation why Tobar did not continue with physical therapy in April 2014: Unfortunately her workman's comp case has been controverted. Thus we will discharge her from skilled PT. (Notably, Tobar had attended all the prescribed physical therapy sessions in February, after Wilson, in January, had impressed upon her the need for consistent treatment.) Second, the Commission's statement that Tobar did not seek medical treatment ... for the next two years is also clearly erroneous; Tobar's medical records show that a year after the EME she sought treatment for both her back and her mental health at Providence Family Medicine Center, where treatment was again deferred after several months only because of her lack of insurance. The Commission also found support for medical stability in the records of PA Hand. But nothing in the records indicates that Hand supported a March 2014 date of medical stability. The Commission, like the Board, summarized a January 2017 chart note as indicating that Tobar had told Hand her lumbar spine symptoms had not changed in the previous three years. The Board did not mention this evidence in its analysis of medical stability, so we cannot say whether the Board relied on it or gave it any weight. Regardless, it is not an accurate summary of the evidence: the chart note relates that Tobar reported to Hand that her pain had improved after the two epidural injections but each time had returned in about three months. The note also reflects that Tobar told Hand that all of the symptoms that [Tobar] complains of today are the same chronic symptoms that she has had since the beginning of all this. Hand's note appears to show that Tobar had the same symptoms from 2013 to 2017 but their severity came and went depending on her treatment. The Commission, like the Board, also relied on the fact that Hand checked the yes box when asked by Remington's attorney whether Tobar's symptoms had remained the same without any improvement for over 45 days. But Hand first saw Tobar in late 2016. Hand never identified a specific date of medical stability; her April 2017 statement that Tobar had not improved for over 45 days could mean that Tobar had become medically stable as recently as early 2017 - three years after the Board's selected date. Remington does not identify any additional evidence that supports a March 2014 date of medical stability. Remington relies on the  general consisten[cy] in the opinions of Dr. Youngblood, Dr. Kirkham, and PA Hand. Dr. Youngblood's report says that Tobar was medically stable at the time of his EME because she would likely have been medically stable two weeks after the injury, but the Board specifically rejected his opinion about a two-week recovery. Dr. Youngblood also testified that he agreed with several of Dr. Kirkham's diagnoses and some of his other observations, but Dr. Kirkham - who first saw Tobar in 2017 - did not offer an opinion about when Tobar became medically stable. And Hand's opinions, as noted above, also came three years after Dr. Youngblood's and did not purport to address the medical stability issue. Our review of the medical stability finding is impeded by the Board's failure to assign weight to the medical evidence and its apparent oversight of key medical records in addition to those mentioned above. 20 Neither the Board nor the Commission discussed Wilson's October 2013 opinions about causation or maximum medical improvement. Also missing from both decisions' analyses is any reference to Tobar's consistent participation in physical therapy in February 2014, as Wilson prescribed; this would seem to be evidence of Tobar's willingness to engage in the physical therapy Wilson recommended in April 2014, had her finances allowed it. The Board noted that Wilson ordered a second epidural steroid injection, but the Board did not identify when it was ordered or acknowledge that Tobar underwent this procedure on March 13, 2014, just a week before the date the Board selected for medical stability. 21 The Commission said Tobar was unable to point to any particular medical evidence the Board failed to consider, but Tobar contended that the Board did not adequately consider Wilson's opinions, and this appears to be true. The Board also failed to mention Wilson's prescription for physical therapy following the second epidural or the note from the physical therapist indicating that Tobar's treatment was discontinued because of Remington's controversion. The Commission thought Tobar's failure to seek medical treatment, including physical therapy, after the EME was important, but Tobar in fact attended a physical therapy evaluation a week after the EME, was advised at that time to participate one to three times a week for six to eight weeks, but was discharged soon thereafter because of the controversion and her lack of insurance. The Board and the Commission also failed to recognize that Providence Family Medicine Center began treating Tobar for back pain in late April 2015; both the Board and the Commission observed that Tobar went for two years without seeking treatment following the EME in March 2014, but this finding was mistaken. We have said that [t]he substantial evidence test is highly deferential, but we still review the entire record to ensure that the evidence detracting from the agency's decision is not dramatically disproportionate to the evidence supporting it such that we cannot 'conscientiously' find the evidence supporting the decision to be 'substantial.'  22 Here we have found no evidence to support the March 2014 date of medical stability selected by the Board. Wilson's opinions contradict Dr. Youngblood's assessments of medical stability, and her prescription of more physical therapy after the second epidural steroid injection implies that Tobar's condition might still have improved with further care. In other words, Wilson's opinions detract from the Board's decision about the date of medical stability, and it is troubling  that the Board failed to mention, evaluate, or weigh this countervailing evidence. In sum, the Board's finding of a March 2014 date of medical stability, affirmed by the Commission, is not supported by substantial evidence. And because the Board and the Commission failed to mention relevant medical evidence - in fact relying on the absence of records for a time when there were records - and neglected to assign weight to the medical evidence it did mention, we must remand this case for further proceedings before the Board.