Opinion ID: 2639523
Heading Depth: 1
Heading Rank: 9

Heading: Medical Commission's Decision as Arbitrary and Capricious

Text: [¶ 42] As we noted at the outset of this opinion, when confronted with an agency decision that has failed to address all material evidence and make findings of fact that enable meaningful review, it is this Court's preference to remand for entry of a new order. If the record before the agency does not support the agency action, if the agency has not considered all relevant factors, or if the reviewing court simply cannot evaluate the challenged agency action on the basis of the record before it, the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation. The reviewing court is not generally empowered to conduct a de novo inquiry into the matter being reviewed and to reach its own conclusions based on such an inquiry. Bush, ¶ 12, 120 P.3d at 181 (quoting Florida Power & Light Co. v. Lorion, 470 U.S. 729, 744, 105 S.Ct. 1598, 1607, 84 L.Ed.2d 643 (1985)). This Court is particularly reluctant to overturn a hearing examiner's determinations of the credibility and weight to be given evidence and will do so only when the determinations are clearly contrary to the overwhelming weight of the evidence. Olivas, ¶ 17, 130 P.3d at 485; Taylor v. State ex rel. Wyoming Workers' Safety & Comp. Div., 2005 WY 148, ¶ 8, 123 P.3d 143, 146 (Wyo. 2005); Brierley v. State ex rel. Wyoming Workers' Safety & Comp. Div., 2002 WY 121, ¶ 16, 52 P.3d 564, 571 (Wyo.2002). [¶ 43] This case presents circumstances that justify this Court in taking the rare steps of, first, overturning the fact finder's determination of the weight to be given a medical opinion, and, second, reversing with directions to enter an order awarding benefits. For the reasons that follow, we hold that the Medical Commission's reliance on the opinion of Dr. Perakos was arbitrary and capricious. We further hold that the Medical Commission's decision to deny benefits is arbitrary and capricious because it is based on inaccurate findings of fact and is contrary to the overwhelming weight of the evidence. [¶ 44] At the Division's direction, Rodgers submitted to an IME by Dr. Perakos. Based on that IME and a review of some of Rodgers' records, Dr. Perakos provided the following opinion with which the Medical Commission agreed and upon which it in part based its decision: As we do not have most of Dr. Tietjen's records I cannot be convinced that there is a causal relationship between his medications and causing his esophageal strictures or dysmotility of his esophagus, particularly in the setting of a normal esophageal motility study obtained by Dr. McElwee within the past two years. Based upon the information we have to a reasonable degree of medical probability there is not a probable causal relationship between the current complaint and the medications used. . . . [¶ 45] Dr. Tietjen treated Rodgers for his gastrointestinal problems from April 1997 through April 2000. The absence of most of his records from Dr. Perakos' review creates a sizable gap in the history on which Dr. Perakos based his opinion, as Dr. Perakos himself acknowledged in his IME report: I next have a difficulty making a direct association with other medications possibly causing his stricture. As I do not have good copies of the photos taken by Dr. Kuckel and I do not have the primary documents from Dr. McElwee, and I have virtually no documents from Dr. Tietjen, it is hard to put this together. I suspect, however, that it would be a big leap to tie medications with the stricture. [¶ 46] The incomplete medical history upon which Dr. Perakos based his opinion in itself raises serious questions concerning the reliability of that opinion. We are not, however, left to guess at the deficiencies created by the incomplete history. Dr. Perakos based his opinion in this case on the assumption that Rodgers did not suffer from gastric outlet obstruction and additionally that Rodgers did not suffer from acid reflux. He testified as follows: Q. And would you disagree that his gastroparesis is caused by the same medicine? A. No, I wouldn't necessarily disagree in that gastroparesis is, as I said earlier, the narcotics will slow down the motion of stomach contents, contents of the small intestine, the contents of the large intestine, so that you can have a slowing of the motility or the actual contractions or peristalsis anywhere in the gastrointestinal tract from narcotics, so I will not disagree. Q. But you would disagree to make the next leap that the esophageal stricture is caused by that? A. That is correct. If, and I believe I said this earlier, if Mr. Rodgers had a gastric outlet obstruction, which he does not have, either at the time of Dr. Tietjen's examination or at the time of Dr. Kuckel's examination, if he had a gastric outlet obstruction, then you can visualize a large volume of material sitting in the stomach, not going anywhere except the one way that is open, and that is in the wrong direction, and that just isn't the case. [¶ 47] Of course, as the Medical Commission observed, Rodgers did in fact suffer from a gastric outlet obstruction and had Dr. Perakos had Rodgers' complete medical history he would have had that information. Additionally, in his IME report, Dr. Perakos stated that [i]f Mr. Rodgers does have significant gastroesophageal reflux disease then that can contribute to worsening of the esophageal stricture. The record is also clear that Rodgers suffers from reflux. It is apparent that the information Dr. Perakos was missing would have changed his opinion from I suspect, however, that it would be a big leap to tie medications with the stricture, to an opinion similar to that of Dr. Kuckel's: the narcotic medications caused gastroparesis, a large volume of material was left sitting in Rodgers' stomach with no where to go but up, and the reflux caused the esophageal stricture. [¶ 48] Given the incomplete medical history and flawed assumptions on which Dr. Perakos based his opinion, we find the Medical Commission's reliance on the opinion arbitrary and capricious. The Medical Commission did not, however, base its decision entirely on the opinion of Dr. Perakos. The Medical Commission also based its decision in part on the opinion of Dr. Kuckel and in part on its finding that [h]ad the medications been responsible for the esophageal stricture, we would expect that the stricture would have appeared far earlier than it did. It is the inaccuracies in the Medical Commission's findings concerning the opinion of Dr. Kuckel that further compel us to find the Medical Commission's decision arbitrary and capricious. [¶ 49] The Medical Commission found Dr. Kuckel's opinion persuasive because he is board certified in internal medicine and board-eligible in gastroenterology. The concern we have with the Medical Commission's reliance on Dr. Kuckel's opinion is not with the credibility of Dr. Kuckel's opinion, but that the Medical Commission misstated his opinion. The Medical Commission found as follows concerning Dr. Kuckel's opinion (emphasis in original): Dr. Kuckel is Board Certified in internal medicine and board-eligible in gastroenterology and was unequivocal in his opinion that the variety of medications being taken by Mr. Rodgers were the primary causative agent of his gastrointestinal problems. Dr. Kuckel described Mr. Rodgers as taking prodigious doses of narcotics. (Kuckel Deposition, p. 30) In response to his attorney's question, . . . real quickly Doctor, his condition, his dysphagia, gastritis, duodenitis, and gastroparesis, do you believe that all of these are caused by or are secondary to his use of pain medication? Dr. Kuckel replied, I believe that this is the case, yes. (Kuckel deposition, page 22) We agree with Dr. Kuckel's conclusions regarding those issues, but note that he was NOT questioned on the espohagitis, hiatal hernia, esophageal stricture, esophageal dilation and Schatzki's ring are not mentioned in his opinion, and we find that those conditions are not related to his narcotic pain medication usage. [¶ 50] We find the Medical Commission's reading of the above-quoted opinion of Dr. Kuckel to be strained and narrow. The inclusion of the terms dysphagia (difficulty swallowing), gastritis and gatroparesis in the causation question arguably covered the gamut of Rodgers' complaints. More importantly, though, the statement that Dr. Kuckel was not questioned concerning Rodgers' esophagitis and esophageal stricture is simply wrong. Dr. Kuckel was repeatedly questioned concerning these conditions and repeatedly gave an unequivocal opinion that Rodgers' pain medications were the ultimate cause of these conditions. For example: Q. And again, under your impressions, could you give me your impressions according to that document? A. Secondary to the medications that he was taking, I had thought that he had symptoms of what was called gastroparesis secondary to his pain medications. Pain medications, narcotics, just about every single one of them, with the exception of a medication he is not on, will cause slowdown of contractions in the gastrointestinal tract. What will happen is there will be no forward motion of food or secretions or acid, and I felt that his problems were secondary to that. When I had gone and done some of his procedures, although it was not readily obvious in the reports, there were times when there were some retained contents which would not have been there had this patient had normal gastroparesis. So my assumption was presumptively and with good reason that his chronic use of narcotic medications was causing gastroparesis. He was retaining food secretions and acid, and these acids, secondary to his hiatal hernia and other complications, were refluxing back into his esophagus. He was structuring down, and this necessitated me to perform esophageal dilatations on him in order for him to eat properly.     Q. Now, as you testify today, do you have, I guess, a medical opinion as to what you believe causes his gastrointestinal problems? A. At the time when I saw him, part of his dyspeptic symptoms were caused by H. pylori. H. pylori as an infection is implicated in causing acid peptic disease and is implicated in causing ulcers. However, it is not implicated in causing gastroparesis. It is not implicated in causing gastroesophageal reflux disease and strictures, so part of his dyspeptic symptoms and part of his pain and I say a small portion of that was caused by that, but once that was treated, that was eliminated. His problems were directly caused by hiswere triggered and I think maintained by his pain medications resulting in gastroparesis, and therefore, he could not clear his acids.     Q. Doctor, you briefly hit on this, I know, but could you explain to me in detail more how you believe pain medications can cause this type of problems? A. Sure. Pain medications in general are CNS depressants, and one of the effects that pain medications have are decreased motility of the gastrointestinal tract. In particular, the large intestine as well as the stomach have decreased motility. This is evidenced by many people who have chronic narcotic use and/or abuse are extremely constipated. People with chronic narcotic use and abuse have what they call gastroparesis. The stomach does not empty in a timely manner. Gastric emptying time is directly reduced almost directly in proportion to amount and duration of narcotic agents used. Of course, it depends on which kind of narcotic agents you're using. Some are stronger than others, but in his case, he was on multiple agents and his ability to clear theclear his gastric contents is severely compromised.     Q. Do you have an opinion as to what caused this stricture? A. My opinion as to what caused the stricture is that reflux of acid and gastric contents up into the esophagus as they were not cleared would cause the stricture. Continuous acid bathing on the distal portion of the esophagus is well documented in causing esophageal strictures.     Q. And that stricture is caused by the pain medicine he takes? A. No. The pain medication in and of itself does not cause it. The pain medication causes gastroparesis, a slowdown in the clearing of the stomach. And therefore, the acid and anything that is left inside the stomach will reflux. It has to go somewhere. [¶ 51] The Medical Commission's finding that Dr. Kuckel did not provide an opinion concerning the cause of Rodgers' esophagitis and esophageal stricture was clearly erroneous. The conclusion the Medical Commission drew from that erroneous finding, that these conditions were not related to Rodgers' narcotic pain usage, is therefore arbitrary and capricious. [¶ 52] Although we have rejected the Medical Commission's reliance on Dr. Perakos' opinion, we do not otherwise need to reweigh any evidence to reach our conclusion that the order denying benefits must be reversed and an order awarding benefits be entered. The Medical Commission accepted the opinion of Dr. Kuckel as persuasive but then misstated the opinion. We likewise accept Dr. Kuckel's opinion as persuasive, and, through our decision, we simply give effect to that opinion.