Opinion ID: 2379412
Heading Depth: 1
Heading Rank: 6

Heading: Substantial Evidence Review of OAH Factual Findings

Text: [¶ 25] We turn now to the OAH's factual findings. Ms. Kenyon claims the hearing examiner's decision to accept Dr. Ruttle's opinion over her treating physician, Dr. Rork's, opinion is not supported by substantial evidence. When conflicting medical opinions are presented at the contested case hearing, the agency has the responsibility, as the trier of fact, to determine relevancy, assign probative value, and ascribe the relevant weight given to the evidence presented. Clark v. State ex rel. Wyoming Workers' Safety & Compensation Div., 934 P.2d 1269, 1271 (Wyo.1997). The [agency] is in the best position to judge and weigh medical evidence and may disregard an expert opinion if it finds the opinion unreasonable or not adequately supported by the facts upon which the opinion is based. Id.; Matter of Goddard, 914 P.2d 1233, 1238 (Wyo. 1996). Spletzer v. State ex rel. Wyo. Workers' Safety & Comp. Div., 2005 WY 90, ¶ 21, 116 P.3d 1103, 1112 (Wyo.2005). We do not re-weigh the evidence, but defer to the agency's decision so long as it is based on relevant evidence that a reasonable mind might accept as supporting that decision. Id., ¶ 22, 116 P.3d at 1112. Chavez v. State ex rel. Wyo. Workers' Safety & Comp. Div., 2009 WY 46, ¶ 18, 204 P.3d 967, 971 (Wyo.2009). [¶ 26] The OAH recognized that the determining factor on the issue of whether or not Ms. Kenyon's total knee replacement was related to her work injury was the physicians' opinions. With regard to those opinions, the hearing examiner concluded: 80. This Office must weigh the opinions offered by Dr. Rork and Dr. Ruttle under the Baxter [3] standards. This Office finds that all the physicians are highly qualified and well trained professionals. This Office also finds that each physician's opinion is equally unequivocal. Thus, this Office must weigh the history and reasoning behind the opinions. 81. Dr. Rork admitted that Kenyon's need for treatment in November 2007 and subsequent July 9, 2008, total [knee replacement] was caused by Kenyon's osteoarthritis which had been present prior to Kenyon's March 19, 2006 work injury; however, Dr. Rork believe[d] that Kenyon's March 19, 2006 work injury was an aggravating factor in Kenyon's ultimate need for total knee replacement. Dr. Rork did not adequately explain how he determined that Kenyon's March 19, 2006 acute right knee injury caused the extensive osteoarthritis, which was noted as early as July 2000, and which led to the July 8, 2008 arthroplasty, but just blankly asserted it was . . . probably what tipped her over the edge. 82. Dr. Rork did not have a good history as to how Kenyon was injured on March 19, 2006 and in fact admitted he had no understanding of what Kenyon was doing at the time of the alleged work injury. Dr. Rork further did not explain why he stated Kenyon had never recovered after the March 29, 2006 surgery, when there was a break in treatment for eighteen months. Further, Dr. Rork did not know of Kenyon's May 2008 golfing incident or Kenyon's June 2008 boating incident. Reviewing the record, Dr. Rork had almost no information regarding Kenyon's recovery and activities between May 2006 and the July 2008 arthroplasty, but rather Dr. Rork based his entire opinion on Kenyon's unsubstantiated statement she never healed after the March 29, 2006 surgery. 83. Dr. Ruttle, on the other hand, had a more complete understanding of Kenyon's history. Dr. Ruttle summarized pages of Kenyon's medical records, performed an examination focused on the cause of Kenyon's need for treatment and obtained a very detailed history from Kenyon. Dr. Ruttle noted that Kenyon's 1999 surgery was more extensive and required a second surgery followed by months of knee pain, whereas? Kenyon's March 29, 2006 surgery was rather minor and after six weeks Kenyon discontinued all treatment. Dr. Ruttle knew of Kenyon's intervening injuries and also used the objective evidence in arriving at his conclusion that Kenyon had recovered from her March 19, 2006 acute injury as of May 2, 2006 and that Kenyon's treatment from November 6, 2007 forward was not related to the March 19, 2006 incident. Dr. Ruttle thoroughly explained the basis for his opinion and did not rely totally on Kenyon's unsubstantiated and less than credible history. Additionally, Dr. Ruttle based his opinion on published and accepted medical research covering the cause of osteoarthritis in knees. 84. Using the Baxter factors, this Office finds the opinion of Dr. Ruttle more persuasive than the opinion of Dr. Rork. Dr. Ruttle had a more thorough history and had a complete understanding of Kenyon's March 19, 2006 injury. Further, Dr. Ruttle thoroughly explained his opinion and supported his findings with established and accepted medical journals. 85. Accordingly, this Office finds Kenyon failed to prove that her November 6, 2007 treatment and subsequent July 9, 2008 right knee arthroplasty was caused by or related to her March 19, 2006 acute knee injury. [¶ 27] Taking aim at specific aspects of the hearing examiner's decision, Ms. Kenyon claims the hearing examiner should not have accepted Dr. Ruttle's reasoning that she had recovered from her March 2006 work related injury on the grounds that she did not seek treatment for her injury for a year and a half. She claims Dr. Ruttle did not take into account that she was incarcerated for five of those months. Besides the obvious problem with this argumenta five month period of incarceration does not explain the eighteen month lapse in treatment, there is nothing in the record indicating that Ms. Kenyon could not have sought treatment for her knee if she needed it while she was incarcerated. [¶ 28] Furthermore, there were other reasons Dr. Ruttle believed that Ms. Kenyon had recovered from her work injury by the time she needed the total knee replacement. He described the relatively minor nature of the 2006 injury and surgery and how that compared with the more serious injury and surgeries in 1999 and 2000. He emphasized that, with the earlier injury, she sought medical treatment when the knee continued to bother her after the surgery. He contrasted that to the fact that she did not seek medical treatment for pain after she recovered from the 2006 surgery. Dr. Ruttle also noted that she lived a fairly active lifestyle after the 2006 surgery, including playing golf on a regular basis. Dr. Ruttle's opinion that Ms. Kenyon had recovered from her 2006 work related injury was reasonable and adequately supported by the facts in the record. See Chavez, ¶ 18, 204 P.3d at 971. As such, there is substantial evidence to support the OAH adoption of his opinion in that regard. [¶ 29] Next, Ms. Kenyon faults the OAH for accepting Dr. Ruttle's opinion because it was based on published and accepted medical research covering the cause of osteoarthritis in the knee. Dr. Ruttle's report included the following statement: Recent work in orthopedic literature has also suggested that despite successful, stabilizing[] anterior cruciate reconstruction, patients with reconstructed anterior cruciate ligament[s] may develop arthritis within the involved knee. Dr. Ruttle testified about the literature at his deposition. He referenced several articles indicating that patients who had ACL reconstruction and meniscetomy have a higher incidence of osteoarthritis than patients who did not. [¶ 30] Initially, we observe that, although the hearing examiner mentioned Dr. Ruttle's statements about the literature in a couple of instances, he did so only briefly and that did not appear to be his primary consideration in accepting Dr. Ruttle's opinion over Dr. Rork's. Instead, it was simply another fact to support Dr. Ruttle's opinion that Ms. Kenyon's osteoarthritis which necessitated the total knee replacement was the result of her earlier injury rather than the 2006 work related injury. Dr. Rork's report also included an extensive rendition of Ms. Kenyon's medical history and medical records and the results of his physical examination of her. The record, therefore, contains relevant evidence that a reasonable mind might accept as adequate to support a conclusion. Dale, ¶ 22, 188 P.3d at 561. [¶ 31] Ms. Kenyon also criticizes the OAH finding that Dr. Ruttle's opinion was more persuasive because he was aware that Ms. Kenyon had suffered some intervening injuries between the 2006 surgery and the 2008 total knee replacement, while Dr. Rork's testimony did not indicate that he was aware of those incidents. This argument is referring to Dr. Ruttle's remark that Ms. Kenyon experienced pain and swelling in May 2008 after playing golf and in June 2008 when she stepped into a boat while fishing. She maintains it was not appropriate to discount Dr. Rork's opinion on the basis that he did not know about the incidents because they occurred after he was deposed in February 2008. However, the OAH allowed Dr. Rork to provide a response to Dr. Ruttle's deposition testimony and report after the contested case hearing. Although Dr. Rork provided an e-mail response, which was admitted into evidence, he did not address the intervening injuries. Thus, the OAH did not err by considering the fact that Dr. Ruttle took the intervening injuries into account in rendering his opinion and Dr. Rork did not. [¶ 32] Ms. Kenyon maintains that her situation is comparable to that presented in Judd, 2010 WY 85, 233 P.3d 956. Ms. Judd suffered from preexisting degenerative arthritis in her knee, but was working full time as a physical therapy aide until she tripped and fell at work, injuring her knee. She had arthroscopic surgery, which the division covered. However, she never recovered her ability to put weight on the knee and eventually underwent total knee replacement. Id., ¶¶ 4-7, 34, 233 P.3d at 959, 969. The Medical Commission denied benefits, reasoning that the preexisting condition, rather than the fall, necessitated the total knee replacement. Id., ¶ 23, 233 P.3d at 966-67. In making that determination, the commission relied on the medical opinions of two independent evaluators instead of Ms. Judd's treating physician. The independent evaluators had concluded that because the fall did not change the underlying knee pathology, that is physically alter the degenerative arthritis, and because Judd's total knee replacement surgery was inevitable, there was no material aggravation of the preexisting condition. Id., ¶ 35, 233 P.3d at 970. [¶ 33] We reversed, concluding that Ms. Judd had satisfied her burden of proving a work related material aggravation of her preexisting condition had led to the total knee replacement. We stated that the commission erred by relying on the independent evaluators' opinions because there is no requirement in Wyoming law that the underlying pathology must change in order to find a material aggravation of a preexisting condition. It was significant, in our view, that her physical condition and abilities changed dramatically after her fall and she did not recover until after the knee replacement surgery was performed. Id., ¶¶ 34-38, 233 P.3d at 969-71. See also, Slaymaker, 2007 WY 65, 156 P.3d 977. [¶ 34] Judd is readily distinguishable from the case at bar because the evidence clearly showed that Ms. Judd had not recovered from her work related injury when she underwent the total knee replacement. In fact, she was unable to put weight on the knee until after the knee replacement surgery. Here, it reasonably can be concluded that Ms. Kenyon recovered after her 2006 injury and surgery and it was clear she went for eighteen months without medical treatment before returning to Dr. Rork for her total knee replacement. [¶ 35] The present case is very similar to Chavez. Mr. Chavez injured his back at work in 1989. He had surgery on his back in 1991, and the division paid for that treatment. Mr. Chavez had a second surgery in 2006, but the division denied benefits for that surgery, reasoning that it was not related to his 1989 work injury. Id., ¶¶ 3-4, 204 P.3d at 968-69. The hearing examiner considered the testimony of Mr. Chavez's treating physician, who testified the 2006 surgery was related to the 1989 work injury, and Dr. Ruttle, who testified the surgery was not related to the work injury but was instead due to the recurrence of what was a chronic, preexisting problem. Id., ¶¶ 13-16, 204 P.3d at 970-71. The Medical Commission accepted Dr. Ruttle's opinion over the treating physician's, and we concluded there was substantial evidence in the record to support that choice. Id., ¶ 19, 204 P.3d at 971-72. In affirming the Medical Commission, we recognized that, in its decision, it had noted several reasons for affording more weight to Dr. Ruttle's opinion than to Mr. Chavez's treating physician's and those reasons were supported by the medical evidence. In particular, the record established that Mr. Chavez had recovered and got better after his 1989 injury and he told his treating physician that his back pain was long standing and did not identify the 1989 incident as the cause of his pain. Id., ¶¶ 17-19, 204 P.3d at 971-72. [¶ 36] As in Chavez, the OAH's decision included a detailed review of Dr. Rork's and Dr. Ruttle's medical opinions and a careful explanation of why it accepted Dr. Ruttle's opinion instead of Dr. Rork's. The underlying facts, including the lapse in medical treatment, Ms. Kenyon's active lifestyle after the 2006 surgery, and the medical evidence showing that she had significant preexisting osteoarthritis supported Dr. Ruttle's opinion that her preexisting condition, rather than the 2006 injury, led to her total knee replacement. The OAH decision to accept Dr. Ruttle's opinion over Dr. Rork's was based on relevant evidence that a reasonable mind might accept as supporting that decision. Id., ¶ 18, 204 P.3d at 971, citing Spletzer, ¶ 22, 116 P.3d at 1112. [¶ 37] Finally, Ms. Kenyon challenges the OAH determination that she was not entirely credible. The hearing examiner made the following factual findings: 19. At [the] hearing, Kenyon was very evasive in answering questions about her treatment after the March 29, 2006 right knee surgery, but eventually admitted she only had three follow-up visits with Dr. Rork. Kenyon claimed that although she quit receiving medical treatment, her knee never recovered. 20. Kenyon alleged she was in constant pain, but was performing physical therapy at home because [of] her continued knee pain. 21. Kenyon testified that she had been active all her life. . . . Kenyon alleged she was never able to return to her normal life activities after the March 29, 2006, surgery but could not explain why she had completely ceased treatment if she was still suffering significant pain. 22. During her cross-examination, Kenyon admitted that for a portion of time after she ceased medical treatment in May 2006 and before she returned for treatment in November 2007, Kenyon was incarcerated. 23. When questioned as to the cause of her incarceration, Kenyon again was extremely evasive and had to be directed to answer the questions. Kenyon claimed she was jailed for a probation violation but would not initially expound. 24. When ordered to thoroughly answer, Kenyon eventually admitted to having been convicted of theft in 2003, which is a crime of dishonesty. Kenyon attempted to minimize her crime by claiming she was convicted of stealing her own money back from an abusive ex-boyfriend. 25. Kenyon admitted that, at the time of the hearing, she was still on probation, even after serving five months in county jail for her prior probation revocation. Throughout all the questioning regarding her conviction, Kenyon was evasive and provided incomplete and what appeared less than truthful answers. 26. Kenyon also admitted on cross examination, grudgingly, that she only sought additional right knee treatment after an incident where she fell out of a boat and when she realized golfing caused additional pain in her right knee. Again, Kenyon attempted to minimize that any activities were the cause of her pain and added that all her pain she associates with the March 19, 2006 work injury. Based upon these findings, the hearing examiner concluded: 53. This Office must first address the credibility of Kenyon as a witness. This Office found Kenyon to be a less than completely credible witness, but not so unbelievable that all of her testimony was rendered useless. Kenyon attempted to evade many questions and had to be instructed to answer the questions posed. Kenyon's demeanor and actions were more indicative of a witness attempting to mislead or not provide complete information. Kenyon would stare down at the floor, look away from the hearing examiner, roll her eyes and otherwise appear less than honest. 54. That being said, Kenyon's testimony in some manner was confirmed by the contemporaneously prepared medical records and therefore this Office was able to determine that at least some of Kenyon's testimony was credible; however, her testimony regarding her criminal history, her continued pain after the March 29, 2006, surgery and her inability to return to normal activities was not believable. [¶ 38] Ms. Kenyon argues that the hearing transcript does not indicate that she had to be instructed to answer questions more thoroughly. After reviewing the transcript, we agree that Ms. Kenyon was not overtly ordered or instructed by the hearing examiner to answer the questions more thoroughly. However, it does appear that her answers were, at times, evasive and not entirely forthcoming. Moreover, the hearing examiner was in the room with Ms. Kenyon. He had the opportunity to observe the witness and hear her testimony and was, therefore, in the best position to judge [her] demeanor, truthfulness and veracity. . . . For this reason, we defer to the fact-finder on credibility findings. Herrera v. State ex rel. Wyo. Workers' Safety & Comp. Div., 2010 WY 103, ¶ 15, 236 P.3d 277, 282 (Wyo.2010). Under these circumstances, we defer to the hearing examiner's findings that Ms. Kenyon was not completely credible and conclude there was substantial evidence to support them. [¶ 39] Affirmed.