Court Opinion

ID: 5123849
Source: CourtListenerOpinion
Date Created: 2021-11-05 20:19:52.519507+00
Date Added: 2024-06-11T08:22:36.091983
License: Public Domain

FILED
                                                                         November 5, 2021
                                                                           EDYTHE NASH GAISER, CLERK
                                                                           SUPREME COURT OF APPEALS
                                                                               OF WEST VIRGINIA

                             STATE OF WEST VIRGINIA

                          SUPREME COURT OF APPEALS

JAMES E. ELLIOTT,
Claimant Below, Petitioner

vs.)   No. 20-0417 (BOR Appeal No. 2055041)
                   (Claim No. 2018011297)

YOUTH SERVICES SYSTEMS, INC.,
Employer Below, Respondent

                             MEMORANDUM DECISION
      Petitioner James E. Elliott, by counsel William C. Gallagher, appeals the decision of the
West Virginia Workers’ Compensation Board of Review (“Board of Review”). Youth Services
Systems, Inc., by counsel Lucinda Fluharty, filed a timely response.

       The issue on appeal is medical treatment. The claims administrator denied a request for a
right total knee replacement on March 13, 2019. On January 2, 2020, the Workers’
Compensation Office of Judges (“Office of Judges”) affirmed the claims administrator’s
decision. This appeal arises from the Board of Review’s Order dated May 27, 2020, in which the
Board affirmed the Order of the Office of Judges.

       This Court has considered the parties’ briefs and the record on appeal. The facts and legal
arguments are adequately presented, and the decisional process would not be significantly aided
by oral argument. Upon consideration of the standard of review, the briefs, and the record
presented, the Court finds no substantial question of law and no prejudicial error. For these
reasons, a memorandum decision is appropriate under Rule 21 of the Rules of Appellate
Procedure.

       The standard of review applicable to this Court’s consideration of workers’ compensation
appeals has been set out under W.Va. Code § 23-5-15, in relevant part, as follows:

               (b) In reviewing a decision of the board of review, the supreme court of
          appeals shall consider the record provided by the board and give deference
          to the board’s findings, reasoning and conclusions .

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               (c) If the decision of the board represents an affirmation of a prior
          ruling by both the commission and the office of judges that was entered on
          the same issue in the same claim, the decision of the board may be reversed
          or modified by the Supreme Court of Appeals only if the decision is in clear
          violation of Constitutional or statutory provision, is clearly the result of
          erroneous conclusions of law, or is based upon the board’s material
          misstatement or mischaracterization of particular components of the
          evidentiary record. The court may not conduct a de novo re-weighing of the
          evidentiary record.

See Hammons v. W. Va. Off. of Ins. Comm’r, 235 W.Va. 577, 582-83, 775 S.E.2d 458, 463-64
(2015). As we previously recognized in Justice v. W. Va. Office Ins. Comm’r, 230 W. Va. 80, 83,
736 S.E.2d 80, 83 (2012), we apply a de novo standard of review to questions of law arising in
the context of decisions issued by the Board. See also Davies v. W. Va. Off. of Ins. Comm’r, 227
W. Va. 330, 334, 708 S.E.2d 524, 528 (2011).

         Mr. Elliott was employed as a maintenance worker for Youth Service Systems, Inc., of
Wheeling, West Virginia. He injured his knee on October 17, 2017, while stepping off of a
ladder while at work. A preliminary radiology report dated October 18, 2017, revealed advanced
arthritis of the right medial compartment; however, there was no fracture or dislocation. The
impression was an intact right knee. Mr. Elliott completed an Employees’ and Physicians’
Report of Injury on October 25, 2017, and the claims administrator held the claim compensable
for strain of the right knee on November 15, 2017.

        In a December 28, 2017, report, orthopedic surgeon Richard Glass, M.D., diagnosed Mr.
Elliott with derangement of the posterior horn of the medial meniscus due to an old tear or injury
of the right knee. Dr. Glass suggested arthroscopic surgery to evaluate the knee and remove any
damaged cartilage. On January 15, 2018, the claims administrator authorized right knee
arthroscopy. An operative report from Ohio Valley Medical Center dated February 8, 2018,
indicates that Dr. Glass conducted arthroscopy of the right knee which produced postoperative
diagnoses of torn medial meniscus of the posterior horn of the right knee and loose body in the
right knee.

        An Independent Medical Evaluation was conducted on June 8, 2018, by Joseph Grady,
M.D., who assessed post right knee arthroscopic partial medial meniscectomy and loose body
removal, persistent right knee pain, and status post partial medial meniscectomy superimposed
on some preexisting degenerative changes. Dr. Grady found that he was at his maximum degree
of medical improvement for any right quadriceps strain since it was not causing any of his
current symptoms. Dr. Grady noted internal derangement of the right knee for which Mr. Elliott
underwent a partial medial meniscectomy on February 8, 2018, by Dr. Glass. He was not found
to be his maximum degree of medical improvement for the right knee. Dr. Grady recommended
that he follow-up with his orthopedic surgeon for the possibility of invasive treatment. Dr. Grady
subsequently provided an Addendum on July 23, 2018, resulting in a 1% permanent partial
disability award on August 14, 2018.

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         A monthly follow-up visit report from Dr. Glass, dated September 13, 2018, indicated
that Mr. Elliott’s diagnosis included unspecified internal derangement of the right knee. It was
also noted that the claims administrator approved an evaluation by a knee specialist. After
evaluation, a Diagnosis Update request was made by Dr. Glass on September 24, 2018, for right
knee derangement of the posterior horn of the medial meniscus, loose body in right knee, other
tear of the right knee medial meniscus, and unspecified right knee internal derangement. Rebecca
Thaxton, M.D., provided a Physician Review on October 18, 2018, for the claims administrator
and reported diagnosis updates of right knee derangement, posterior horn medial meniscus tear,
and loose body in the right knee. The discussed additional conditions were added to the claim by
the claims administrator on October 25, 2018.

       On September 28, 2018, Mr. Elliott was seen and evaluated by Carl Quinion, M.D, at
Ohio State University, after referral from Dr. Glass. An x-ray performed during that examination
revealed “severe medial joint space narrowing, subchondral sclerosis and osteophyte formation.”
Dr. Quinion reported he had a “long conversation with patient regarding treatment options for his
condition including anti-inflammatory, bracing, physical therapy, and possible future need for
arthroplasty.” Mr. Elliott advised Dr. Quinion that he would like to follow-up with a surgeon to
discuss partial versus total knee arthroplasty for his severe arthritis.

        On November 21, 2018, Dr. Glass submitted a request for a total knee replacement. The
request for total knee replacement surgery was reviewed by Dr. Thaxton, who in a Physician
Review report dated January 14, 2019, opined that Mr. Elliott’s knee symptoms pre-dated the
injury in the claim and that he returned to a baseline level of function. Dr. Thaxton noted that the
arthroplasty surgery on February 8, 2018, found “degenerative changes down to subchondral
bone on the medial aspect of his tibial plateau and some mild degenerative changes in the medial
femoral condyle.” She further reported that an MRI from May 22, 2018, showed “advanced
degenerative change of the medial compartment.” Although the lateral meniscus was intact, there
was “degenerative narrowing of the intervening joint space, myxoid degenerative change of the
posterior horn of the medial meniscus, small effusion, small-ossified body lateral aspect of the
suprapatellar bursa, and coincidental enchondroma within the distal femoral shaft.” Dr. Thaxton
opined that the changes observed were not acute changes related to the work injury, other than
the absence of the medial meniscus. Dr. Thaxton recommended that authorization for total knee
replacement be denied.

        On January 22, 2019, the claims administrator issued an Order denying authorization for
a right total knee replacement. Mr. Elliott grieved the claims administrator’s decision, and on
March 13, 2019, the StreetSelect Grievance Board Determination recommended the denial be
affirmed. An Order was then issued on March 13, 2019, denying authorization of a right total
knee replacement based upon Dr. Thaxton’s recommendations. Mr. Elliott protested the claims
administrator’s denial of his request for right total knee replacement surgery.

        Mr. Elliott submitted his deposition taken on April 23, 2019, where he testified that he
has worked for the employer for a little over four years. On the day of injury, he was to patch a
ceiling where plaster had fallen. While turning to get off the ladder, his knee snapped and
popped, and he fell onto the floor. Mr. Elliott testified that he hurt his knee at work a year prior
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to his injury while carrying furniture out of a house when the steps came away from the house.
He was given anti-inflammatories and was able to continue working. He reported that his left
knee has given out on him from time to time. Mr. Elliott listed his current pain level as being an
“8” and stated that it never stops hurting.

        Dr. Glass’s deposition was taken on August 1, 2019, and he testified that Mr. Elliott’s
right knee condition is post-traumatic, not degenerative. He stated that the MRI of December 7,
2017, which was taken two months after the injury, noted a medial meniscus tear, which likely
occurred as a result of the injury. It also showed a bone infarct involving the distal femoral shaft,
which had probably been there for a long time and is not related to the injury. There was
preexisting edema on both sides of the joint in the medial compartment related to degenerative
disease and was not the result of the injury of October 17, 2017,. Dr. Glass noted that there were
large areas of complete cartilage loss in the medial compartment that was not suggestive of
something from the injury less than two months prior. Although Dr. Glass testified that the
recommended total knee replacement would be for osteoarthritis of Mr. Elliott’s knee, he stated
“he probably has some traumatic arthritis that has caused the problem also.” Dr. Glass also stated
that nowhere in Dr. Quinion’s report did he give an indication as to the etiology of Mr. Elliott’s
osteoarthritis. It was his opinion that the October 17, 2017, injury caused a discrete new injury;
however, that discrete new injury was a medial meniscus tear.

        Victoria Langa, M.D., a Board-certified orthopedic surgeon, issued a Record Review
report on September 3, 2019. Dr. Langa opined that at the time of Mr. Elliott’s injury, he already
had documented preexisting degenerative arthritis in his right knee involving the medial joint
compartment. The arthroscopic procedure confirmed the degenerative changes. She disagreed
with Dr. Glass’s description in the medical records that the degenerative arthritis is
posttraumatic. Dr. Langa opined that there is nothing in the medical records to suggest that Mr.
Elliott’s degenerative arthritis is posttraumatic in nature. Because arthritis is not an accepted
condition in the claim, Dr. Langa opined that the denial of the request for right total knee
replacement was appropriate.

         In an Order dated January 2, 2020, the Office of Judges affirmed the claims
administrator’s denial of right total knee replacement surgery. The Office of Judges found that
the claims administrator’s Order is supported by the January 14, 2019, Physician Review report
of Dr. Thaxton. Dr. Thaxton determined that the total knee replacement would be for
degenerative osteoarthritis of the right knee, which predated the current claim. Dr. Thaxton
opined that total knee replacement should not be authorized. The Office of Judges also found that
the claims administrator’s denial of total knee replacement surgery is supported by the Record
Review report of Dr. Langa, who disagreed with Dr. Glass’s description of the degenerative
arthritis being posttraumatic. Instead, Dr. Langa opined that the medical records document
preexisting degenerative arthritis in Mr. Elliott’s right knee. Because arthritis is not an accepted
condition in the claim, Dr. Langa stated that the denial of the request for right total knee
replacement was appropriate.

        At deposition, Dr. Glass agreed that Mr. Elliott had preexisting degenerative changes of
his right knee; however, Dr. Glass stated that he “probably has some traumatic arthritis that
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cause the problem also.” Dr. Glass testified that the October 17, 2017 injury caused a discrete
new injury in the form of a medial meniscus tear. In addressing Dr. Glass’s opinion that Mr.
Elliott was in need of total knee arthroplasty for unilateral posttraumatic osteoarthritis of the
right knee, the Office of Judges determined that the medical evidence fails to support a need for
total knee replacement at this time and that the procedure would be due to a preexisting
degenerative condition, which is not one of the compensable conditions in the claim. On May 27,
2020, the Board of Review adopted the findings of fact and conclusions of law of the Office of
Judges and affirmed the decision to deny Mr. Elliott’s request for total knee replacement surgery.

       After review, we agree with the decision of the Office of Judges, as affirmed by the
Board of Review. The evidence of record includes x-rays and an operative report from February
8, 2018, revealing preexisting degenerative conditions in Mr. Elliott’s right knee. Dr. Thaxton
and Dr. Langa opined that the preexisting degenerative arthritis was causing Mr. Elliott’s knee
problems and that surgery would not be warranted for any compensable condition in the claim.
Thus, the preponderance of the evidence fails to support that Mr. Elliott is entitled to a total knee
replacement for any approved condition in the claim, nor has he proved that such treatment is
reasonable and necessary to treat his approved compensable conditions.

                                                                                          Affirmed.

ISSUED: November 5, 2021

CONCURRED IN BY:

Chief Justice Evan H. Jenkins
Justice Elizabeth D. Walker
Justice Tim Armstead
Justice John A. Hutchison
Justice William R. Wooton

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