Court Opinion

ID: 4378107
Source: CourtListenerOpinion
Date Created: 2019-03-18 16:02:35.165347+00
Date Added: 2024-06-11T14:49:28.472686
License: Public Domain

In the United States Court of Federal Claims
                                        No. 16-1664V
             (Filed Under Seal: February 28, 2019 | Reissued: March 18, 2019) ∗

                                                 )
    KELLI TENNESON,                              )   Keywords: Motion for Review; Vaccine
                                                 )   Act; Contemporaneous Medical Records;
                       Petitioner,               )   Shoulder Injury Related to Vaccine
                                                 )   Administration (SIRVA)
    v.                                           )
                                                 )
    SECRETARY OF HEALTH AND HUMAN                )
    SERVICES,                                    )
                                                 )
                       Respondent.               )
                                                 )

Ronald C. Homer and Meredith Daniels, Conway Homer, P.C., Boston, MA, for Petitioner.

Daniel A. Principato, Trial Attorney, Torts Branch, Civil Division, U.S. Department of Justice,
Washington, DC, with whom were Alexis B. Babcock, Assistant Director, Catharine E. Reeves,
Deputy Director, C. Salvatore D’Alessio, Acting Director, and Joseph H. Hunt, Assistant
Attorney General, for Respondent.

                                     OPINION AND ORDER

KAPLAN, Judge.

        The Secretary of Health and Human Services (“the HHS Secretary” or “the Secretary”)
seeks review of the ruling of Chief Special Master Nora B. Dorsey finding Petitioner Kelli
Tenneson entitled to compensation under the National Vaccine Injury Compensation Program,
42 U.S.C. §§ 300aa-10 et seq. (“the Vaccine Act”). Specifically, the Secretary challenges as
arbitrary, capricious, and contrary to law the Chief Special Master’s factual finding that Ms.
Tenneson suffered a shoulder injury within forty-eight hours of receiving a flu vaccination.

       For the reasons that follow, the Court finds the Secretary’s arguments unpersuasive. The
Secretary’s motion for review is therefore DENIED.

∗
  This opinion was previously issued under seal on February 28, 2019. The parties were given
the opportunity to propose redactions on or before March 14, 2019. Because the parties have not
filed proposed redactions, the Court reissues its decision in its entirety.
                                        BACKGROUND

I.      The Evidence Before the Chief Special Master

         On October 6, 2015, Kelli Tenneson, who was then fifty-eight years old, received an
intramuscular flu vaccination from her primary care provider, Kaiser Permanente-Colorado.
Pet’r’s Ex. 1, at 1, ECF No. 7-2. According to an affidavit she executed in connection with this
litigation, the vaccination was administered “very high up on [her] left arm, almost at [her]
shoulder.” Pet’r’s Ex. 6, ¶ 2, ECF No. 8-1.

       Ms. Tenneson asserts that the day after she received the vaccination, she woke up with
extreme pain in her shoulder, which “started in the exact area where the shot was given.” Id. ¶ 3.
By the end of that evening, she states, she experienced “sharp pains all the way down [her] left
arm.” Id.

        Although she alleges that she continued to experience shoulder pain in the months that
followed, Ms. Tenneson did not seek medical care for her shoulder until January 2016 and did
not actually see a physician for the injury until the end of March 2016. Id. ¶¶ 4–6. The central
issue raised by the Secretary’s request for review is whether, in light of that delay, it was
arbitrary, capricious, and contrary to law for the Chief Special Master to credit Ms. Tenneson’s
testimony that her shoulder injury manifested itself within forty-eight hours of her October 6,
2015 vaccination.

         Ms. Tenneson explained in her affidavit that she decided to “wait it out” rather than
seeking medical care immediately because she is “not one who easily goes to the doctor” and
because she “had never heard of a flu vaccine causing this type of sustained pain.” Id. ¶¶ 3–4.
Ms. Tenneson’s husband, Michael Tenneson, as well as her son, Josh, provided supporting
affidavits concerning the effects of the vaccination. Pet’r’s Ex. 8, 9, ECF Nos. 8-3, 8-4. Michael
Tenneson stated that his wife had complained of severe pain the day after she received her flu
shot and that she “could not lift her left arm above her shoulder without being in pain.” Pet’r’s
Ex. 8, ¶ 1. According to Mr. Tenneson, in the days and months that followed, “the pain in her left
upper arm still remained without any mobility above the shoulder.” Id. ¶ 2. He stated that “on
numerous occasions while lying in bed at night, I heard her moan while she moved around in
bed, trying to find a comfortable position to somewhat alleviate her pain.” Id. “On several
occasions,” according to Mr. Tenneson, Ms. Tenneson’s pain kept them both awake. Id.

        Similarly, Josh Tenneson testified by affidavit that, beginning in late October 2015, he
noticed that his mother, who babysat his infant daughter four days a week, was for the first time
having difficulties lifting things above her head and lifting the baby. Pet’r’s Ex. 9, ¶¶ 1–2. He
further testified that when he asked his mother if something was wrong, “she mentioned that she
had been unable to lift her arm above her head since the vaccination” but that “[n]either of us
thought much of it at the time and assumed the symptoms would dissipate.” Id.

        On December 17, 2015, Ms. Tenneson called Kaiser to request a letter of good health.
Pet’r’s Ex. 14, ¶ 2, ECF No. 21-1. The letter, which state law requires all employees of
preschools to submit to their employer, is a one-page document affirming that the employee had
been examined within the past year, that she had no communicable diseases, and that she was

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able to work with children. Id. ¶¶ 2–3; see also Pet’r’s Ex. 2, at 78, ECF No. 7-3 (call record
reflecting a request by Ms. Tenneson for a “letter stating she has been seen within the last year
and is in good health”). According to Ms. Tenneson, her primary care physician signed the form
based on the prior year’s physical exam, which had taken place several months before she
received the influenza vaccination. Pet’r’s Ex. 14, ¶ 4.

       Ms. Tenneson’s sister-in-law testified by affidavit that as the family gathered for
Christmas in 2015 she was “very surprised to see that not only was [Ms. Tenneson’s] arm not
any better, but it actually seemed to be worse.” Pet’r’s Ex. 11, ¶ 4, ECF No. 10-2. Ms. Tenneson
nonetheless “continued to tough it out” until January 2016, when she scheduled a March 30
appointment to see her primary care doctor about the shoulder pain. Pet’r’s Ex. 14, ¶ 5; see also
Ruling on Entitlement (“CSM Dec.”) at 4, ECF No. 31.

       In the meantime, on the morning of January 22, 2016, Ms. Tenneson called Kaiser
complaining of blood in her urine and pressure “in [her] lower extremities,” which she had been
experiencing for the preceding two days. Pet’r’s Ex. 14, ¶ 6; Pet’r’s Ex. 2, at 80. The nurse who
took her call listed her “chief complaint” as a “UTI” (urinary tract infection). Pet’r’s Ex. 2, at 80.

        Later that day, Ms. Tenneson and her family left for a trip to the mountains. While
traveling, Ms. Tenneson asserts, she experienced “excruciating low back pain.” Pet’r’s Ex. 14,
¶ 6. After the family arrived at their destination, Ms. Tenneson reported to an emergency room at
Middle Park Medical Center, which she characterizes as a “small mountain hospital” in a “small
ski town in Colorado.” Id. ¶ 7. Hospital records indicate that she complained of severe right
flank/abdominal pain, low back pain, blood in her urine, discomfort with urination, nausea, and
vomiting. Pet’r’s Ex. 3, at 1, ECF No. 7-4.

       The physical exam section of the emergency room report includes a heading entitled
“extremities.” The following terms were checked off: “non-tender,” “nrml ROM [range of
motion],” and “no pedal edema.” Id. at 2.

       Ms. Tenneson asserts that she remained at the emergency room for several hours but
“only saw the doctor for approximately 2–3 minutes.” Pet’r’s Ex. 14, ¶ 7. She also states that
although her shoulder was painful during the visit, her abdominal pain was worse. Id. ¶ 8.

        Ms. Tenneson was diagnosed with a kidney stone. Id. Despite the notations in the
extremities section of the emergency room report, Ms. Tenneson testifies that she “was never
given an exam of [her] upper extremities, and specifically, [her] left shoulder was never tested
for tenderness or range of motion.” Id. ¶ 9. Furthermore, she states that when she was preparing
to undergo a CT scan, she informed the technician that she had been unable to raise her hands
above her head after having received a flu shot several months prior. Id. ¶ 10. This alleged
comment is not reflected in the accompanying records. Ms. Tenneson’s husband and son, who
were with her during her visit to the emergency room, submitted supplemental affidavits that are
generally consistent with Ms. Tenneson’s recollection. See generally Pet’r’s Ex. 15, 16, ECF
Nos. 21-2, 21-3.

       After she was released from the emergency room, Ms. Tenneson had two follow-up
phone calls with Kaiser. The first was with a nurse on January 25, and the second was with her

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primary care physician, Dr. Deja Vandeloo, on January 26. Pet’r’s Ex. 2, at 84–85. In a summary
of these calls, Dr. Vandeloo noted that pain medication was not then-needed because Ms.
Tenneson was feeling better and that the kidney stone should pass within two weeks. Id. at 85.
There is no mention of shoulder pain complaints in the call summaries.

        On March 30, 2016, Ms. Tenneson kept the appointment that she had made in January to
address her shoulder pain. Id. at 86. Medical records documenting the visit contain the notation
“left arm pain since flu shot 10/15, pain all the way down arm. Can barely move arm now. Just
hasn’t gotten better. Wake her up at night. Does watch her grand-baby and can lift her but hard
time getting seatbelt, etc.” Id. at 89. Dr. Vandeloo conducted a musculoskeletal evaluation which
confirmed Ms. Tenneson’s complaints. She found “limited ROM left shoulder—can only
abduct/extend to approx 80-90 degrees and can only get a few more degrees passively.” Id. at 90.

        Dr. Vandeloo diagnosed Ms. Tenneson with adhesive capsulitis of the left shoulder. Id. at
91. She advised Ms. Tenneson to take over-the-counter pain medications and perform a series of
stretching exercises. Id. Ms. Tenneson was also given a referral for physical therapy and an
orthopedist. Id. Dr. Vandeloo’s referral to the orthopedist noted “left shoulder problem: frozen
shoulder—[patient] has had pain ever since flu shot 10/15 [with] no injury. Worsening ROM
over last 5 months.” Id. at 89.

         Records summarizing the March visit indicate that Dr. Vandeloo discussed Ms.
Tenneson’s injury with “shot line,” which the Court understands to be a telephone service that
provides advice to health care workers about vaccines and their administration. Id. at 91; see also
Pamela K. Strohfus, Sharon R. Brown & Paige Potratz, Effective and Sustainable Advice Line
Promotes Safe Vaccine Practices, 14 Int’l J. of Evidence-Based Healthcare 130 (2016),
https://scholarworks.boisestate.edu/nursing_facpubs/174/. According to Dr. Vandeloo’s notes,
she was advised by “shot line” that the injury was “not due to [the] vaccine but they can’t
comment on administration.” Pet’r’s Ex. 2, at 91. Dr. Vandeloo also apparently consulted with
an orthopedist who “felt [it] unlikely [that] this is all related to flu shot” but who acknowledged
that Ms. Tenneson “certainly could have developed a frozen shoulder if she hasn’t moved it x 5
mo” since the flu vaccination. Id. at 91, 97.

        Ms. Tenneson met with Robert L. Webers, a physical therapist, on April 13, 2016. Id. at
99. Mr. Webers noted that Ms. Tenneson “got flu shot in [] Oct 2015, [and] since then she has
had pain.” Id. During the appointment, Ms. Tenneson advised Mr. Webers that her sleep was
“disturbed” and that her pain level was “6/10.” Id. Mr. Webers opined that her symptoms were
“consist[e]nt with Adhesive capsulitis.” Id. at 100. He recommended that Ms. Tenneson continue
treatment every ten days for four weeks to increase her range of motion. Id.

        A few weeks later, on April 27, 2016, Ms. Tenneson was examined by Dr. Tracy
Frombach, an orthopedist. Id. at 105. Dr. Frombach noted “5 months left shoulder pain since flu
shot 10/15 . . . [v]ery limited [range of motion]” and “[m]ild degenerative changes [in her] left
shoulder.” Id. at 107–08. Dr. Frombach described Ms. Tenneson’s conditions as “Adhesive
capsulitis of the left shoulder shortly following a flu injection in October 2015” and “[l]eft
rotator cuff syndrome.” Id. at 110. During the visit, Ms. Tenneson received a left subacromial
injection after which her “range of motion was pain free” but still limited. Id. Dr. Frombach

                                                 4
advised Ms. Tenneson to continue with physical therapy and to follow up in six weeks. Id. at
111.

       According to Dr. Frombach, Ms. Tenneson’s adhesive capsulitis was “almost completely
resolved” by October 2016. Pet’r’s Ex. 4, at 45, ECF No. 7-5. Ms. Tenneson continued physical
therapy through at least March 2017. See Pet’r’s Ex. 13, at 33, ECF No. 16-2.

II.    The Vaccine Claim

        On December 20, 2016, Ms. Tenneson filed a petition for compensation under the
Vaccine Act. She alleged that the flu vaccination she had received on October 6, 2015 had
caused a shoulder injury. Pet. for Vaccine Compensation at 1, ECF No. 1. Her case was assigned
to the Chief Special Master the next day for evaluation by the Special Processing Unit. See ECF
Nos. 4, 5.

        On June 19, 2017, the HHS Secretary filed a Rule 4(c) report opposing Ms. Tenneson’s
claim. See generally Resp’t’s Rule 4(c) Report, ECF No. 18. The Secretary argued that Ms.
Tenneson had not established that the onset of her symptoms occurred within forty-eight hours of
her vaccination, which is the time period that the relevant medical literature establishes for most
vaccine-related shoulder injuries. Id. at 5. To the contrary, according to the Secretary, the
contemporaneous medical records indicated that her shoulder pain began some three to six
months after the vaccination. Id.

       In a July 26, 2017 scheduling order, the Chief Special Master observed that based on the
record before her, it appeared that Ms. Tenneson’s claim “generally meets the requirements for
SIRVA [(shoulder injury related to vaccine administration)].” Scheduling Order at 1, ECF No.
19. She further noted that “petitioner’s affidavit together with the records evidence onset within
48 hours of petitioner’s vaccination.” Id. The Chief Special Master further stated that she did not
“believe this [was] a claim that should to go to hearing,” but that it rather “should be resolved for
a reasonable amount.” Id. She further “encourage[d] [Ms. Tenneson] to make a reasonable
demand upon [the Secretary].” Id.

        In a status report filed on October 2, 2017 the Secretary stated his intent to oppose Ms.
Tenneson’s claim and conveyed his unwillingness to engage in settlement discussions. Status
Report at 1, ECF No. 25. At a status conference held on October 18, 2017, the Chief Special
Master gave Ms. Tenneson the option of requesting a fact hearing or a ruling on the record; Ms.
Tenneson elected the latter. See Scheduling Order at 1, ECF No. 26. Counsel for the government
did not object to having the case decided on the record, stating instead that “he would defer to
petitioner on how to proceed” and indicating that he was “amenable” to disposition on the record
without a hearing. Id.

        The Chief Special Master gave the parties thirty days to file additional evidence. Id. at 2.
In addition, the parties were advised that the record would include two medical journal articles
that concern shoulder injuries caused by vaccinations. Id. at 1; see also S. Atanasoff, Shoulder
injury related to vaccine administration (SIRVA), 28 Vaccine 8049 (2010) (entered into the
record as Court Ex. I, ECF No. 26-1); Marko Bodor & Enoch Montalvo, Vaccination-related

                                                  5
shoulder dysfunction, 25 Vaccine 585 (2007) (entered into the record as Court Ex. II, ECF No.
26-2).

III.      The Chief Special Master’s Decision

        On March 30, 2018, the Chief Special Master issued a decision holding that Ms.
Tenneson was entitled to compensation under the Vaccine Act. CSM Dec. at 12. She found that
“the affidavits submitted by and on behalf of petitioner and the medical records work in tandem
to provide preponderant evidence that petitioner’s shoulder pain began within 48 hours of her
October 6, 2015 flu vaccination.” Id. at 8. The Chief Special Master declined the government’s
invitation to infer that Ms. Tenneson’s account of the onset of her injury was unreliable because
she waited several months to seek medical treatment. Id. at 7. The Chief Special Master
concluded that the delay in seeking treatment was more relevant to the severity of the shoulder
injury than to the date it began. Id. She reasoned that “[p]etitioner’s account is detailed, cogent
and corroborates the statements she made to her health care providers.” Id. “Moreover,” the
Chief Special Master observed, in her experience, “petitioner’s affidavits and medical records
together reflect a pattern of treatment consistent with and similar to many other SIRVA claims.”
Id.

        The Chief Special Master applied, and found satisfied, the three-prong test for
establishing causation set forth in Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274,
1278 (Fed. Cir. 2005). The Chief Special Master took judicial notice of the fact that HHS added
SIRVA to the Vaccine Injury Table for the influenza vaccine effective March 21, 2017, after Ms.
Tenneson filed her claim. CSM Dec. at 9. Based on that designation, the Chief Special Master
found that prong one of the Althen test—which requires preponderant evidence of a medical
theory causally connecting the flu vaccine to SIRVA—was met. Id. at 9–10; see also Althen, 418
F.3d at 1278. The Chief Special Master further concluded that there was a logical sequence of
cause and effect between the vaccination and Ms. Tenneson’s shoulder injury (prong two of the
Althen test) based on an application of the Qualifications and Aids to Interpretation (“QAI”) for
SIRVA codified at 42 U.S.C. § 100.3(c)(10). CSM Dec. at 10–11. 1 Finally, the Chief Special

1
    That provision states in pertinent part that:
          A vaccine recipient shall be considered to have suffered SIRVA if such recipient
          manifests all of the following:
                  (i) No history of pain, inflammation or dysfunction of the affected shoulder
                  prior to intramuscular vaccine administration that would explain the alleged
                  signs, symptoms, examination findings, and/or diagnostic studies occurring
                  after vaccine injection;
                  (ii) Pain occurs within the specified time-frame;
                  (iii) Pain and reduced range of motion are limited to the shoulder in which
                  the intramuscular vaccine was administered; and

                                                    6
Master found that the third prong of the Althen test—requiring a proximate temporal relationship
between the vaccine and injury—was satisfied based on her factual finding that the onset of Ms.
Tenneson’s SIRVA pain (the morning after she was vaccinated) fell within the two-day period
that HHS recognizes as the relevant medically accepted timeframe for such onset. Id. at 12; see
also Althen, 418 F.3d at 1278.

        Having found Ms. Tenneson entitled to compensation, the Chief Special Master
instructed the parties to confer to discuss damages. Damages Order at 1, ECF No. 32. After
several months of discussion, the Secretary filed a proffer of award on November 16, 2018,
recommending a lump-sum payment of $88,017.82. Proffer on Award of Compensation at 1,
ECF No. 50. The Chief Special Master accepted the recommendation and issued an order
awarding damages in that amount to Ms. Tenneson on November 19, 2018. See Dec. Awarding
Damages at 2, ECF No. 51.

IV.    The Government’s Motion for Review

        On December 18, 2018, the Secretary filed the present motion for review which requests
that the Court reverse the Chief Special Master’s ruling on entitlement. See generally Resp’t’s
Mot. for Review (“Resp’t’s Mot.”), ECF No. 52. The Secretary advances two interrelated
arguments in support of his motion. First, he argues that the Chief Special Master’s ruling
contravenes 42 U.S.C. § 300aa-13(a)(1), which prohibits a special master from finding a
petitioner entitled to compensation “based on the claims of a petitioner alone, unsubstantiated by
medical records or by medical opinion.” Second, he argues, the Chief Special Master’s factual
finding as to the onset date of Ms. Tenneson’s shoulder injuries was arbitrary and capricious
because the Chief Special Master credited Ms. Tenneson’s testimony, notwithstanding its alleged
inconsistency with certain contemporaneous medical records (i.e., the notes concerning Ms.
Tenneson’s calls to her primary care physician in December 2015 and January 2016, and the
record of her emergency room visit in January 2016).

        For the reasons set forth below, the Court concludes that the Secretary’s arguments lack
merit. Accordingly, the motion for review is DENIED and the Chief Special Master’s ruling on
entitlement is SUSTAINED. 2

                                          DISCUSSION

I.     Jurisdiction

       Congress established the National Vaccine Injury Compensation Program in 1986 to
provide a no-fault compensation system for vaccine-related injuries and deaths. Figueroa v.

               (iv) No other condition or abnormality is present that would explain the
               patient’s symptoms (e.g. NCS/EMG or clinical evidence of radiculopathy,
               brachial neuritis, mononeuropathies, or any other neuropathy).
2
 The Court has determined that oral argument is unnecessary in this case. Accordingly, its
decision is based on the record, the Chief Special Master’s ruling on entitlement, and the parties’
briefs.

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Sec’y of Health & Human Servs., 715 F.3d 1314, 1316–17 (Fed. Cir. 2013). The Vaccine Act is
remedial legislation that should be construed in a manner effectuating its underlying spirit and
purpose. Id. at 1317.

        To secure compensation under the Vaccine Act, a petitioner must prove by a
preponderance of the evidence that the injury at issue was caused by a vaccine. See 42 U.S.C.
§§ 300aa-11(c)(1), -13(a)(1)(A). Where a petitioner sustains an injury in association with a
vaccine listed in the Vaccine Injury Table, causation is presumed. Broekelschen v. Sec’y of
Health & Human Servs., 618 F.3d 1339, 1341–42 (Fed. Cir. 2010) (citing 42 U.S.C. § 300aa-
11(c)(1)(C)(i); Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1374 (Fed. Cir.
2009)). Where, as in this case, the injury is not listed in the Table, the petitioner must prove
causation-in-fact. Broekelschen, 618 F.3d at 1342 (citing Moberly ex rel. Moberly v. Sec’y of
Health & Human Servs., 592 F.3d 1315, 1321 (Fed. Cir. 2010)). To discharge that burden, “a
petitioner must show that the vaccine was ‘not only a but-for cause of the injury but also a
substantial factor in bringing about the injury.’” Stone v. Sec’y of Health & Human Servs., 676
F.3d 1373, 1379 (Fed. Cir. 2012) (quoting Shyface v. Sec’y of Health & Human Servs., 165 F.3d
1344, 1352–53 (Fed. Cir. 1999)). “Once the petitioner has demonstrated causation, she is entitled
to compensation unless the government can show by a preponderance of the evidence that the
injury is due to factors unrelated to the vaccine.” Broekelschen, 618 F.3d at 1342 (citing Doe v.
Sec’y of Health & Human Servs., 601 F.3d 1349, 1351 (Fed. Cir. 2010); 42 U.S.C. § 300aa-
13(a)(1)(B)).

        A petition seeking compensation under the Vaccine Act is filed in the Court of Federal
Claims, after which the Clerk of Court forwards it to the Chief Special Master for assignment to
a special master. 42 U.S.C. § 300aa-11(a)(1). The special master to whom the petition is assigned
“issue[s] a decision on such petition with respect to whether compensation is to be provided
under the [Vaccine Act] Program and the amount of such compensation.” Id. § 300aa-
12(d)(3)(A). That decision is subject to review in the Court of Federal Claims and in the Court of
Appeals for the Federal Circuit. Mahaffey v. Sec’y of Health & Human Servs., 368 F.3d 1378,
1383 (Fed. Cir. 2004) (citing 42 U.S.C. § 300aa-12(d)(3)(A)).

II.    Standard of Review

       The Vaccine Act grants the Court of Federal Claims jurisdiction to review the record of
the proceedings before a special master, and authority, upon such review, to:

       (A) uphold the findings of fact and conclusions of law of the special master and
       sustain the special master’s decision,

       (B) set aside any findings of fact or conclusion of law of the special master found
       to be arbitrary, capricious, an abuse of discretion, or otherwise not in accordance
       with law and issue its own findings of fact and conclusions of law, or

       (C) remand the petition to the special master for further action in accordance with
       the court’s direction.

Id. § 300aa-12(e)(2); see also Vaccine Rule 27.

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         On review of the special master’s decision, the Court applies the arbitrary and capricious
standard to factual findings and the “not in accordance with law” standard to legal rulings.
Moberly, 592 F.3d at 1321. “The arbitrary and capricious standard of review is difficult for an
appellant to satisfy with respect to any issue, but particularly with respect to an issue that turns
on the weighing of evidence by the trier of fact.” Lampe v. Sec’y of Health & Human Servs., 219
F.3d 1357, 1360 (Fed. Cir. 2000). The Court “do[es] not reweigh the factual evidence, assess
whether the special master correctly evaluated the evidence, or examine the probative value of
the evidence or the credibility of the witnesses,” because those “are all matters within the
purview of the fact finder.” Porter v. Sec’y of Health & Human Servs., 663 F.3d 1242, 1249
(Fed. Cir. 2011) (citing Broekelschen, 618 F.3d at 1349). “[A]s long as a special master’s finding
of fact is ‘based on evidence in the record that [is] not wholly implausible,’” the Court must
uphold it. Id. (quoting Cedillo v. Sec’y of Health & Human Servs., 617 F.3d 1328, 1338 (Fed.
Cir. 2010) (alteration in original)). “[T]he standard of review is uniquely deferential” to special
masters’ decisions. Milik v. Sec’y of Health & Human Servs., 822 F.3d 1367, 1376 (Fed. Cir.
2016) (quoting Hodges v. Sec’y of Health & Human Servs., 9 F.3d 958, 961 (Fed. Cir. 1993)).
“If the special master ‘has considered the relevant evidence of record, drawn plausible inferences
and articulated a rational basis for the decision,’ then reversible error is ‘extremely difficult to
demonstrate.’” Id. (quoting Hines v. Sec’y of Health & Human Servs., 940 F.2d 1518, 1528
(Fed. Cir. 1991)).

III.   The Secretary’s Arguments

        As noted above, the Secretary challenges the Chief Special Master’s decision on two
interrelated grounds. First, he argues that the Chief Special Master found that Ms. Tenneson’s
shoulder injury manifested itself within forty-eight hours of her vaccination based solely on her
testimony and that of her family, and “unsubstantiated by medical records or medical opinions.”
Resp’t’s Mot. at 1–2 (citing 42 U.S.C. § 300aa-13(a)). This finding, according to the Secretary,
contravened “the express terms of the Vaccine Act,” specifically 42 U.S.C. § 300aa-13(b)(2). Id.
at 8–9. Second, he argues that, in any event, the Chief Special Master’s onset determination was
arbitrary and capricious because: 1) she gave undue weight to Ms. Tenneson’s affidavits, which
he alleges were inconsistent with the contemporaneous medical records; and 2) she improperly
relied upon her own personal experience (rather than record evidence) in determining the weight
to be given to the records of Ms. Tenneson’s emergency room visit. Id. at 14–17.

       For the reasons set forth below, the Secretary’s legal argument lacks merit. Further, the
Secretary has failed to persuade the Court to second guess the Chief Special Master’s factual
finding regarding the onset date of Ms. Tenneson’s shoulder injury. That finding must be upheld
because it is based on reasonable inferences that the Chief Special Master drew from all of the
evidence in the record, informed by her significant experience adjudicating similar cases under
the Vaccine Program.

       A. The Secretary’s Argument That the Chief Special Master’s Decision Violates 42
          U.S.C. § 300aa-13(a)(1)

        The Secretary’s first argument, as noted above, is that the Chief Special Master’s
decision contravenes 42 U.S.C. § 300aa-13(a)(1). That provision states that a petitioner is
entitled to compensation where the special master finds that she has demonstrated by

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preponderant evidence “the matters required in the petition by section 300aa–11(c)(1) of [Title
42]” and “that there is not a preponderance of the evidence that the illness, disability, injury,
condition, or death described in the petition is due to factors unrelated to the administration of
the vaccine described in the petition.” 42 U.S.C. § 300aa-13(a)(1)(A)–(B). The provision further
states that “[t]he special master or court may not make such a finding based on the claims of a
petitioner alone, unsubstantiated by medical records or by medical opinion.” 42 U.S.C. § 300aa-
13(a)(1). According to the Secretary, it is this prohibition that the Chief Special Master violated
by allegedly relying entirely upon Ms. Tenneson’s testimony (and that of her family members) to
establish the onset date of her shoulder injury.

         The Secretary’s argument is flawed because it relies on a faulty premise—i.e., that the
Chief Special Master’s finding as to the onset date of Ms. Tenneson’s shoulder injury was based
entirely on affidavits that were “unsubstantiated by medical records or by medical opinion.” In
fact, the Chief Special Master did not rely exclusively on the affidavits to determine the onset
date. She also cited the records of Ms. Tenneson’s visit with Dr. Vandeloo on March 30, 2016,
during which she reported that her shoulder pain had begun immediately after the October 2015
flu shot. CSM Dec. at 7. In addition, the Chief Special Master cited the records of Ms.
Tenneson’s physical therapy evaluation on April 13, 2016, which recount that “[patient] got a flu
shot in Oct. 2015, and since then she has had pain.” Id. Finally, the Chief Special Master relied
upon the records of Ms. Tenneson’s visit with the orthopedist on April 27, 2016, which stated
that “the day following her flu shot she had significant pain in the left shoulder and had limited
range of motion.” Id.

        To be sure, these medical records were not prepared contemporaneously with the event in
question (i.e., the onset of Ms. Tenneson’s shoulder injury). But Ms. Tenneson’s delay in seeking
treatment for her shoulder injury does not deprive the records of probative value as to the date
Ms. Tenneson began experiencing shoulder pain and disability. Thus, the records are probative
because they “contain information supplied to or by health professionals to facilitate diagnosis
and treatment of medical conditions” and “[w]ith proper treatment hanging in the balance,
accuracy has an extra premium.” Cucuras v. Sec’y of Health & Human Servs., 993 F.2d 1525,
1528 (Fed. Cir. 1993). Given this presumption that an individual seeking treatment is likely to
supply accurate information to their health care provider, the Court is unpersuaded by the
Secretary’s argument, which seems to assume—with no supporting evidence, direct or
circumstantial—that Ms. Tenneson intentionally deceived her doctors regarding the onset date of
her shoulder pain.

        Finally, and in any event, it is not readily apparent that 42 U.S.C. § 300aa-13(a)(1)
precludes a special master or court from finding an onset date supported by preponderant
evidence based on lay testimony, as the Secretary contends. That provision’s language states that
an adjudicator cannot find that a petitioner has demonstrated by preponderant evidence “the
matters required in the petition by section 300aa–11(c)(1) of [Title 42]” without substantiation
by medical evidence or medical opinion. But 42 U.S.C. § 300aa-13(a)(1) does not speak to the
circumstances under which particular subsidiary facts relevant to causation (such as, for
example, the fact of a vaccination or the onset date of an injury) may be established by
preponderant evidence on the basis of lay testimony, so long as the overall finding of causation is
sustained by medical records or medical opinion. Centmehaiey v. Sec’y of Dep’t of Health &
Human Servs., 32 Fed. Cl. 612, 621, aff’d sub nom. Centmehaiey v. Sec’y of Health & Human

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Servs., 73 F.3d 381 (Fed. Cir. 1995) (noting that 42 U.S.C. § 300aa–13(a)(1) does not bar
recovery where there is no contemporaneous, documentary proof of a vaccination) (citing Brown
v. Sec’y of Dep’t of Health & Human Servs., 18 Cl. Ct. 834, 839 (1989), rev’d on other grounds,
920 F.2d 918 (1990)).

        As the Court sees it, the prohibition in 42 U.S.C. § 300aa-13(a)(1) is against finding a
cause-and-effect relationship between a vaccine and an injury without any substantiation by
medical evidence or opinion. See Johnston v. Sec’y of Dep’t of Health & Human Servs., 22 Cl.
Ct. 75, 78 (1990) (“Section 300aa–13(a)(1) is a general admonition. It is an effort to weed out
claims which have no medical basis to support the injury.”); Camery v. Sec’y of Health &
Human Servs., 42 Fed. Cl. 381, 389 (1998) (same). In any event, the Court has found that the
onset date for Ms. Tenneson’s shoulder injury was supported by medical records. It therefore
need not decide whether it is always impermissible to rely on lay testimony to establish an onset
date.

        In short, there is no merit to the Secretary’s argument that the Chief Special Master
committed a legal error when she found that the onset date of Ms. Tenneson’s shoulder injury
was within forty-eight hours of her vaccination. The Court turns, therefore, to the Secretary’s
argument that the onset date finding—if not legally erroneous—was nonetheless arbitrary and
capricious.

       B. The Secretary’s Argument That the Chief Special Master’s Factual
          Determination Regarding the Date of Onset Was Arbitrary and Capricious

        The Secretary’s second argument is that the Chief Special Master’s onset determination
was arbitrary and capricious because she found Ms. Tenneson’s testimony regarding the onset
date of her symptoms credible, notwithstanding what the Secretary asserts was its inconsistency
with contemporaneous medical records. Specifically, the Secretary takes the Chief Special
Master to task for not giving greater weight to Ms. Tenneson’s failure to seek treatment more
promptly or to mention her shoulder condition when she called her physician’s office in
December 2015 and January 2016. He contends that these actions (or failures to act), undermine
the credibility of Ms. Tenneson’s testimony as to the onset date of her injury. Moreover, the
Secretary argues, contemporaneous medical records (the records of Ms. Tenneson’s January
emergency room visit) affirmatively indicated a lack of tenderness in her extremities and a
normal range of motion, results which are inconsistent with Ms. Tenneson’s contention that she
had been suffering significant shoulder pain since the preceding October.

        As the Court explained above, however, its function on review of the decision of a
special master is not to “reweigh the factual evidence, assess whether the special master correctly
evaluated the evidence, or examine the probative value of the evidence or the credibility of the
witnesses.” Porter, 663 F.3d at 1249. In fact, the Court is required to uphold factual findings that
are “based on evidence in the record that [is] not wholly implausible.” Cedillo, 617 F.3d at 1338.

        Here, the Chief Special Master provided an entirely reasonable explanation for crediting
Ms. Tenneson’s testimony (and that of her family) regarding the onset date of her shoulder
injury, notwithstanding her delay in seeking treatment. She observed that Ms. Tenneson’s
medical records “repeatedly and consistently placed the onset of her condition within 48 hours of

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her vaccination.” CSM Dec. at 7. She found that “the fact that [Ms. Tenneson] delayed seeking
treatment for her shoulder symptoms does not negate the value of her treatment records or render
this evidence not credible, although it may speak to the severity of her injury.” Id. She further
found “reasonable and credible” Ms. Tenneson’s affidavits explaining her “pattern of treatment
and reports to her physicians” (which were consistent with those of her family members), and
observed that in her (considerable) experience, “petitioner’s affidavits and medical records
together reflect a pattern of treatment consistent with and similar to many other SIRVA claims.”
Id.

        Further, the Chief Special Master provided an adequate explanation for her decision not
to give greater weight to the emergency room treatment records which reflected that checkmarks
had been placed next to boxes for “non-tender,” “nrml ROM,” and “no pedal edema” under the
“extremities” portion of the physical exam section. As the Chief Special Master explained, Ms.
Tenneson “was seen at the ER on January 22, 2016 for a [urinary tract infection] and kidney
stones which are extremely painful conditions for which petitioner was seeking urgent medical
attention.” Id. at 8. Ms. Tenneson’s testimony was that her shoulders were not examined and that
the doctor spent no more than two or three minutes with her. Id. at 4. And the Chief Special
Master noted that, in her experience, “thorough physical examinations are not conducted in the
ER setting for issues beyond or unrelated to the reason for that visit . . . in contrast to a general or
physical examination conducted by a primary care physician or orthopedist.” Id. at 8. Similarly,
the Chief Special Master found that the calls on January 25 and 26 were “clearly in follow-up to
petitioner’s emergency room visit for her UTI and kidney stones, and the description of lack of
pain relates accordingly to those issues.” Id.

        The Secretary contends that the Chief Special Master “erred by relying upon her own
undisclosed (and effectively unrebuttable) opinion about the standard of care in emergency
rooms based on her personal experience.” Resp’t’s Mot. at 17. According to the Secretary, “the
Chief Special Master’s determination that no extremities exam was performed here . . . was
purely speculative.” Id. The Court finds this argument unpersuasive. The Chief Special Master
did not speculate; she found credible Ms. Tenneson’s testimony that—notwithstanding the
checked boxes—her left shoulder was not examined during her visit. The Chief Special Master
reasonably noted that a more thorough examination is often not conducted for issues beyond
those for which the patient presents at an emergency room. After all, the purpose of an
emergency room visit is to receive emergency treatment, not a comprehensive health check-up.

       That the Chief Special Master is “not herself a medical doctor” and “has no direct
knowledge of the particular medical facility in question” does not mean she cannot rely on her
experience and common sense to evaluate evidence. See id. Indeed, a special master may rely
upon her “accumulated expertise” gained adjudicating Vaccine Act claims. Hodges, 9 F.3d at
961. That includes her accumulated expertise reviewing a variety of medical reports and
considering numerous medical procedures, including those produced and undertaken in the
emergency room setting.

        It was equally sensible for the Chief Special Master not to draw conclusions about the
onset of Ms. Tenneson’s shoulder injury from her contacts with one of the medical assistants at
Kaiser in December, when she was seeking a “letter of good health” to enable her to work at a

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preschool. The impetus for those contacts was limited to securing the required certification for
employment purposes.

        Finally, the Court gives no credence to the Secretary’s claim that the Chief Special
Master’s decision resolved “a question of extraordinary importance to the Vaccine Injury
Compensation Program” and that “if allowed to stand, the decision . . . would set a troubling
precedent that petitioner can establish entitlement to compensation simply by averring an
appropriate onset in an affidavit even where the contemporaneous medical records do not
support these claims, and in fact affirmatively show a lack of symptoms.” See Resp’t’s Mot. at
12. For one thing, to the extent that the Secretary wished to challenge the credibility of Ms.
Tenneson’s affidavit regarding the onset date (or the affidavits of her family members), he could
have requested the opportunity to cross-examine her at a hearing. Instead, he agreed that the case
could be decided on the record. Second, it is not true that Ms. Tenneson’s claims as to onset have
no support in the medical documentation. As described above, Ms. Tenneson’s allegations in her
affidavit regarding the onset date are consistent with what she told her physicians and medical
professionals when she sought treatment for her injury. And finally, the Chief Special Master
explained why, in the context of the facts of this case, she did not give weight to the perfunctory
notations regarding Ms. Tenneson’s “extremities” that were contained in the emergency room
records.

       In short, the Chief Special Master’s decision was based on all of the evidence before her.
She provided an adequate and reasonable explanation for her finding that Ms. Tenneson’s
shoulder injury manifested within forty-eight hours of the vaccination. The inferences she drew
and the conclusions she reached were not unreasonable. The Court, accordingly, sustains her
decision.

                                        CONCLUSION

       On the basis of the foregoing, the Respondent’s motion for review is DENIED and the
Chief Special Master’s ruling on entitlement is SUSTAINED. The Clerk is directed to enter
judgment accordingly.

        IT IS SO ORDERED.

                                                     s/ Elaine D. Kaplan
                                                     ELAINE D. KAPLAN
                                                     Judge

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