Opinion ID: 6336160
Heading Depth: 2
Heading Rank: 1

Heading: The Request to Add Cervical Radiculopathy

Text: ICG contends that Mr. Moore is not focusing on the proper issue on appeal. While it argues that “there has not been a request to add cervical radicular pain or radiculopathy as compensable conditions[,]” to the claims administrator, the record reveals that this request was before the Office of Judges. When Mr. Moore’s protests to the four claim administrator’s orders proceeded to the Office of Judges, his counsel requested that cervical radiculopathy be added as a compensable diagnosis, and ICG responded to the issue. At this point, the Office of Judges had the statutory authority to rule on the request and modify the order of the claims administrator. 15 West Virginia Code § 23-5-9(d) (2007) provides that when a party appeals an order of a claims administrator, the Office of Judges “shall, based on the determination of the facts of the case and applicable law, render a decision affirming, 15 For instance, in Best Buy v. Parrish, No. 15-1153, 2016 WL 7105264 (W. Va. Dec. 6, 2016) (memorandum decision), the claims administrator approved the claim for the diagnosis of a right foot crush injury. On appeal, the Office of Judges determined that the diagnosis of complex regional pain syndrome should also be compensable when six treating physicians opined that the claimant suffered from this condition. Id. at . So, the Office of Judges added this additional diagnosis even when the claimant had not formally requested it on a diagnosis update form. This decision was affirmed by the Board of Review and this Court. 11 reversing or modifying the action protested.” 16 Instead of applying its findings of fact to the issue, the Office of Judges abdicated its responsibility and defaulted to the diagnosis code listed on the form—ignoring the reference to Dr. France’s office notes that supported Mr. Moore’s request. 17 This ruling elevated form over substance in violation of West Virginia Code § 23-1-1(b) (2007), which provides that it is the “intent of the Legislature that this chapter be interpreted so as to assure the quick and efficient delivery of indemnity and medical benefits to injured workers at a reasonable cost to the employers[,] . . . and workers’ compensation cases shall be decided on their merits[.]” The dissent claims that the Office of Judges actually considered Mr. Moore’s request to add cervical radiculopathy as a compensable condition but found that the weight of the objective evidence did not support this diagnosis. So, it faults us for not giving deference to the Office of Judges’ remark that “the record raises significant questions regarding the very diagnosis of radiculopathy in this case[,]” as well as its comment that “the objective medical evidence of record does not support a diagnosis of true 16 W. Va. Code § 23-5-9(d). West Virginia Code § 23-5-9(e) provides that the Office of Judges may also remand a claim to the claims administrator “for further development of the facts or administrative matters as, in the opinion of the administrative law judge, may be necessary for a full and complete disposition of the case.” 17 The Office of Judges stated that Mr. Moore’s counsel argued “that the opinions of Drs. France, Vaglienti, and Guberman support[ed] the conclusion that the claimant’s cervical pain with radiculopathy is a compensable condition in the claim.” The Office of Judges stated that in Dr. France’s diagnosis update request, he “referred to his office notes of May 8, 2018, and August 9, 2018.” And it discussed Dr. France’s May 8, 2018, office notes and stated that his “assessment was right C6 radiculopathy[.]” 12 radiculopathy.” This was, of course, pure dictum and not fact finding because it never ruled on Mr. Moore’s request. And while an administrative law judge is tasked with weighing the evidence and resolving contradictory medical opinions, he is not free to set his own expertise against that of all physicians who have personally examined Mr. Moore. 18 The dissent also invokes West Virginia Code § 23-5-15(d), which says this Court may reverse a finding of the Office of Judges or the Board of Review only when there is a “material misstatement or mischaracterization of particular components of the evidentiary record.” But even if we assume that the Office of Judges addressed Mr. Moore’s request to add cervical radiculopathy and rejected it—an argument even ICG does not advance—we are not swayed by the dissent’s appeal to give deference to an opinion that is contrary to every examining physician of record. 18 See e.g., Burns v. Colvin, 156 F. Supp. 3d 579, 583 (M.D. Pa. 2016) (“[N]o reasonable mind would find the ALJ’s evidence to be adequate when the ALJ reject[ed] every medical opinion in the record with only lay reinterpretation of medical evidence.”); see also Todd v. Heckler, 587 F. Supp. 1129, 1133 (W.D. Ky. 1984) (quoting Ragan v. Finch, 435 F.2d 239, 241 (6th Cir.1970), cert. denied, 402 U.S. 986, 91 S.Ct. 1685, 29 L.Ed.2d 152 (1971)) (“While the ALJ may choose between contradictory medical opinions or reject a medical opinion that is contradicted by other evidence of record, he is not free to set his own expertise against that of a physician who has personally examined the claimant.”). 13 The record is clear that Mr. Moore’s request to add cervical radiculopathy as a compensable condition was squarely before the Office of Judges and the Board of Review. So, it is properly before this Court on appeal. B. Cervical Radiculopathy is Causally Connected to the Injury As noted above, Mr. Moore argues that the decisions of the Office of Judges and Board of Review are legally wrong. He contends that cervical radiculopathy should be added as a compensable condition under (1) Gill because it is a discrete new injury arising from the workplace injury; and (2) Charlton because the workplace injury aggravated or accelerated his preexisting, but asymptomatic, cervical degenerative disc disease causing this new diagnosis. Mr. Moore states Drs. Vaglienti, France, and Guberman agree that cervical radiculopathy is causally connected to the compensable injury. Because these assignments of error are closely related, we consider them together. 19 This Court has addressed issues of compensability when claimants had preexisting noncompensable injuries or diseases—both symptomatic and asymptomatic. These highly fact-specific issues are ultimately causal connection determinations based on the medical evidence coupled with the nature and severity of the compensable injury. We 19 ICG does not directly respond to these arguments, nor does it cite Charlton. As previously noted, ICG argues that the request to add C5-6 spondylosis with C6 radiculopathy as a compensable condition was properly rejected under Gill. 14 begin with Charlton, where the claimant developed debilitating ulcerated feet as a result of working in coal mine water containing magnetite, sulphuric acid, grease, oil, and kerosene. 20 Mr. Charlton’s claim was originally denied because he had a preexisting, noncompensable blood vessel disease known as Buerger’s Disease that may have made him prone to developing skin problems. 21 But this Court reversed the ruling on appeal because the evidence showed that Mr. Charlton’s ulcerated feet were causally related to his work, which required him to stand in mine water. 22 We held that: The fact that an employee, injured in performing services arising out of and incidental to his employment, was already afflicted with a progressive disease that might some day have produced physical disability, is no reason why the employee should not be allowed compensation, under Workmen’s Compensation Act, for the injury, which, added to the disease, superinduced physical disability. 23 Charlton is similar to the case before us because Mr. Moore’s work injury aggravated his degenerative disc disease, which was previously asymptomatic, causing cervical radiculopathy. 20 160 W. Va. at 665, 236 S.E.2d at 242. 21 Id. at 667, 236 S.E.2d at 243. 22 Id. Id. at 665, 236 S.E.2d at 242, Syl. Pt. 1 (quoting Syl., Hall v. Comp. Comm’r, 110 23 W. Va. 551, 159 S.E. 516 (1931)). 15 Even though Mr. Moore had no prior back injuries or symptoms related to his degenerative disc disease, our holding in Gill is still applicable because the principle is the same. Mr. Gill had significant prior back injuries along with an extensive history of treatment for lumbar radiculopathy and degenerative disc disease; he was symptomatic for years before his compensable back injury. 24 Mr. Gill’s claim was approved for lumbar and thoracic sprain, but when his treatment provider requested authorization for certain procedures, he listed four diagnostic codes that were not compensable diagnoses. 25 After the request for treatment was denied by the claims administrator, Mr. Gill protested and the Office of Judges added those four diagnostic codes to the claim even though no formal request was made, and the evidence showed no causal connection between those diagnoses and the compensable injury. 26 The Board of Review reversed the decision and concluded that the diagnoses were not compensable. 27 On appeal, this Court affirmed, but we 24 236 W. Va. at 739, 783 S.E.2d at 859. 25 This Court noted “that no physician requested the diagnostic codes 724.4 (neuritis/radiculitis), 724.3 (sciatica), 722.52 (degeneration of lumbosacral IVD), and 724.8 (facet syndrome) be added as compensable” diagnoses in the claim. Id. at 742, 783 S.E.2d at 861. 26 Id. 27 Id. at 740, 783 S.E.2d at 860. 16 addressed the question of when the aggravation of a preexisting condition could be held compensable. 28 In Gill, we discussed a line of cases where we applied Charlton “for the proposition that a preexisting injury does not preclude a new compensable injury from arising.” 29 And in syllabus point 3 of Gill, this Court crafted a general rule that: A noncompensable preexisting injury may not be added as a compensable component of a claim for workers’ compensation medical benefits merely because it may have been aggravated by a compensable injury. To the extent that the aggravation of a noncompensable preexisting injury results in a [discrete] new injury, that new injury may be found compensable. 30 So, a claimant has the burden of proving that the compensable injury exacerbated, accelerated, or worsened the preexisting condition or disease causing a new distinct injury. 31 The Supreme Court of Louisiana has created the following rebuttable presumption in cases like these to help facilitate compensability rulings: A plaintiff-employee’s disability will be presumed to have resulted from an employment accident if before the accident the plaintiff-employee was in good health, but 28 Id. at 744, 783 S.E.2d at 864. 29 236 W. Va. at 745, 783 S.E.2d at 865. 30 Id. at 738, 783 S.E.2d at 858. 31 Id. 17 commencing with the accident the symptoms of the disabling condition appear and continuously manifest themselves, provided that the evidence shows that there is a reasonable possibility of causal connection between the accident and the disabling condition. This presumption is not a conclusive one; rather, it compels the defendant to come forward with sufficient contrary evidence to rebut it. 32 We also find this to be a helpful tool considering the prevalence of degenerative disc disease. 33 We now hold that a claimant’s disability will be presumed to have resulted from the compensable injury if: (1) before the injury, the claimant’s preexisting disease or condition was asymptomatic, and (2) following the injury, the symptoms of the disabling disease or condition appeared and continuously manifested themselves afterwards. There still must be sufficient medical evidence to show a causal relationship between the compensable injury and the disability, or the nature of the accident, combined with the other facts of the case, raises a natural inference of causation. This presumption is not conclusive; it may be rebutted by the employer. A simple recurrence of the same symptoms inherent in the etiology of the preexisting condition or disease is not sufficient to meet this burden of showing a causal 32 Hammond v. Fid. & Cas. Co. of New York, 419 So. 2d 829, 831 (La. 1982) (citations omitted); see also Whitten v. Patterson UTI Drilling Co., LLC, 294 So. 3d 590, 598 (La. App. 2 Cir. 2020) (“The presumption of causation hinges on a finding of sufficient medical evidence to show a reasonable possibility of a causal relation between the accident and disability.”). 33 See note 5, above. 18 connection. 34 For instance, in Moss v. Blackhawk Mining, LLC, 35 the claimant injured his head, neck, and shoulders, when he was struck by a rock in February 2017 while working in the coal mines. The claim was held compensable for concussion and right shoulder contusion. 36 The claims administrator denied Mr. Moss’s request to add cervical sprain and C7 radiculopathy to the claim. That decision was affirmed by the Office of Judges and Board of Review because Mr. Moss had a history of cervical spine issues dating back to 2009; he was diagnosed with cervical radiculopathy, which was symptomatic and required treatment, years before the compensable injury. 37 On appeal, this Court agreed with the conclusion of the Board of Review because “[m]edical records prior to the compensable injury indicate that Mr. Moss suffered from essentially the same cervical symptoms and conditions that he reported post-injury.” 38 So, no causal connection was demonstrated. 34 See e.g., Trosper v. Armstrong Wood Prod., Inc., 273 S.W.3d 598, 607 (Tenn. 2008) (“We reiterate that the employee does not suffer a compensable injury where the work activity aggravates the pre-existing condition merely by increasing the pain. However, if the work injury advances the severity of the pre-existing condition, or if, as a result of the pre-existing condition, the employee suffers a new, distinct injury other than increased pain, then the work injury is compensable.”). 35 No. 19-0721, 2020 WL 6559077 (W. Va. Nov. 6, 2020) (memorandum decision). 36 Id. at . 37 Id. 38 Id. at . 19 In this case, we agree with Mr. Moore that had the Office of Judges properly applied Gill and Charlton to its findings of facts it would have granted his request to add cervical radiculopathy as a compensable condition. 39 The evidence showed that Mr. Moore’s degenerative disc disease was asymptomatic, and that the compensable injury caused him to develop cervical radiculopathy, a new distinct injury. In his February 14, 2019, letter, Dr. Vaglienti explained that Mr. Moore had Degenerative Disease of his neck, which was asymptomatic until the new injury occurred on November 14th, 2016. Had this injury never occurred it is possible that the Radiculopathy would never have occurred. . . . Given the force of the injury and the reported minimal findings of the MRI, it is probable that this Radiculopathy would have occurred even in the absence of Cervical Degenerative Disease. Drs. France and Guberman also opined that Mr. Moore’s cervical radiculopathy was causally connected to the compensable injury. And while Dr. Jin stated that degenerative disc changes are the most common cause of radiculopathy in the general population, she also believed that Mr. Moore’s compensable injury triggered that condition leading to cervical radicular pain. 40 39 We note that the Office of Judges did not discount any physician’s opinion for being not credible. 40 See Narum v. Liberty Nw. Ins. Corp., 206 P.3d 964, 970 (Mont. 2009) (upholding compensability ruling when medical professionals agreed that claimant “was (continued . . .) 20 For these reasons, we find that the Office of Judges and Board of Review committed clear legal error by not modifying the claims administrator’s September 17, 2018, order and granting Mr. Moore’s request to add cervical radiculopathy as a compensable condition of the claim.