Court Opinion

ID: 9889890
Source: CourtListenerOpinion
Date Created: 2023-10-11 18:04:09.452742+00
Date Added: 2024-06-11T12:48:48.919168
License: Public Domain

IN THE SUPERIOR COURT OF THE STATE OF DELAWARE

MICHELLE A. CLINE,                       )
                                         )
     Claimant Below-Appellant,           ) C.A. No. N22A-11-003 FWW
                                         )
           v.                            )
                                         )
THE NEMOURS FOUNDATION,                  )
                                         )
     Employer Below-Appellee.            )

                          Submitted: July 27, 2023
                         Decided: October 11, 2023

                       MEMORANDUM OPINION

                On Appeal from the Industrial Accident Board:
                     REVERSED and REMANDED

Jessica Lewis Welch, Esquire, DOROSHOW, PASQUALE, KRAWITZ &
BHAYA, 1208 Kirkwood Highway, Wilmington, Delaware 19805, Attorney for
Appellant Michelle A. Cline.

Keri L. Morris-Johnson, Esquire, MARSHALL DENNEHEY WARNER
COLEMAN & GOGGIN, 1007 N. Orange Street, Suite 600, P.O. Box 8888,
Wilmington, Delaware 19899, Attorney for Appellee The Nemours Foundation.

WHARTON, J.
                                I.   INTRODUCTION

        Michelle A. Cline (“Cline”) filed a Notice of Appeal on November 14, 2022

seeking a review of the October 13, 2022 decision by the Industrial Accident Board

(“Board”), mailed October 17, 2022. Cline contends that the Board erred when it

denied her Petition for Additional Compensation, concluding that she was not

entitled to additional compensation for total knee replacement surgery.

        In this appeal, Cline asks the Court to determine whether the Board committed

legal error, or abused its discretion, by failing to apply the proper legal standards as

set forth by the Delaware Supreme Court and incorrectly applying the Delaware

Healthcare Practice Guidelines (“Guidelines”) in its application of 19 Del. C. § 2322.

She also asks the Court to determine whether the Board’s decision that her medical

treatment was not reasonable and necessary was supported by substantial evidence.

Specifically, Cline asks the Court to consider whether the Board failed to make an

individualized determination of the reasonableness of her treatment under

Brittingham v. St. Michael’s Rectory,1 and whether it misinterpreted the Guidelines

as requiring the “exhaustion of conservative treatment” rather than the “exhaustion

of all reasonable conservative treatment” before a knee replacement is reasonable.

She also asks the Court to consider whether the Board’s decision to accept the

opinion of her employer’s expert medical witness, Dr. Eric Schwartz (“Dr.

1
    788 A.2d 519 (Del. 2002).
                                           2
Schwartz”), rather than the opinion of her treating physician, Dr. James Rubano

(“Dr. Rubano”), was supported by substantial evidence. After considering the three

relevant paragraphs of the Board’s decision regarding the legal standard it applied

and the factual support for its decision, the Court concludes that it is unable to say

with confidence that the Board’s decision is free from legal error and supported by

substantial evidence. Specifically, the Court is unable to conclude that the Board

considered whether “all reasonable conservative treatment had been exhausted” as

to Cline’s treatment specifically and not generally as to anyone in her position.

Further, since the Board’s decision is almost totally conclusory, the Court cannot

say that the Board’s determination that Cline’s total knee replacement surgery was

not reasonable and necessary was supported by substantial evidence. Therefore, the

Court finds that the Board’s decision was not free from legal error and was not

supported by substantial evidence.            Accordingly, the Board’s decision is

REVERSED and REMANDED for further proceedings consistent with this

Opinion.

                 II.   FACTUAL AND PROCEDURAL CONTEXT

         Cline has appended a Joint Stipulation of Facts for the hearing before the

Board on September 23, 2022 to her Opening Brief on appeal.2 That Stipulation

simply recites, in pertinent part, that: (1) Cline sustained a compensable work related

2
    Stip. of Facts, App. to Op. Br. at A1., D.I. 13.
                                             3
injury to her right knee while in the course and scope of her employment with

Nemours; (2) as a result of her injuries, she underwent a total right knee replacement

surgery with Dr. Rubano on May 17, 2021; and (3) she was paid total workers’

compensation benefits until her return to work following surgery.3 The Board set

out the procedural posture of the case as well as a detailed summary of the evidence

presented at the hearing before the Board on September 23, 2021 in its decision.4

Since neither party takes exception to the Nature and Stage of the Proceedings or the

Summary of the Evidence set out in the Board’s decision, the Court accepts them.5

          On March 15, 2021, Cline sustained a compensable injury to her right knee

while she was working for Nemours when a pediatric patient kicked her in the knee

and punched her in the face.6 Two months later, on May 17, 2021, Dr. Rubano

performed a total knee replacement surgery to treat her right knee injury. Cline filed

a Petition for Additional Compensation on January 31, 2022 seeking

acknowledgment of the compensability of the total knee replacement surgery.7

Nemours disputed the reasonableness, necessity and causal relationship of the

surgery to the work injury.8

3
  Id.
4
  Cline v. Nemours Foundation, No. 1509418, at 2-9, (I.A.B. Oct. 13, 2022), App.
to Op. Br. at A112-22, D.I. 13.
5
  Id.
6
  Id. at 2.
7
  Id.
8
    Id.
                                          4
       The Board held a hearing on September 23, 2022.9 At the hearing, Cline

presented the deposition testimony of Dr. Rubano, a board certified orthopedic

surgeon with a subspeciality in hip and knee replacement surgeries, who is also a

certified provider under the Delaware Workers’ Compensation Healthcare System.10

Dr. Rubano opined to a reasonable medical probability that the total knee

replacement was reasonable and necessary.11 He testified that Cline had a medial

meniscus tear and arthritis, and that, while the meniscal tear could have contributed

to Cline’s pain, her arthritis was the primary pain generator. 12 Were it not for the

work injury, Cline’s arthritis would not have become symptomatic.13

       Dr. Rubano testified that he began treating Cline on April 9, 2021.14 He

reviewed reports and films of X-rays and an MRI and felt that both reports

downplayed the extent of Cline’s arthritis.15 In his opinion, the X-rays demonstrated

arthritis in the patella femoral joint and the MRI demonstrated moderate to severe

arthritis, particularly underneath the kneecap, under the patella femoral joint.16 Cline

had a meniscal tear and advanced medial and lateral arthritic changes underneath the

9
  Id.
10
   Id.
11
   Id.
12
   Id.
13
   Id.
14
   Id.
15
   Id.
16
   Id. at 3.
                                           5
kneecap.17 Dr. Rubano added that a direct trauma or blow to the knee can cause the

kneecap to impact against the femur and exacerbate or accelerate arthritis or post-

traumatic arthritis.18     With Cline, the injury accelerated her preexisting

asymptomatic arthritis requiring the treatment he performed.19

       When Dr. Rubano first saw her, Cline was having significant difficulty

performing her activities of daily living.20 She had tried to return to light duty after

the injury, but her knee gave out, causing her to nearly collapse.21 Dr. Rubano’s

notes from Cline’s initial appointment indicated that she had tried conservative

interventions such as taking time off from work and taking anti-inflamatories.22 He

discussed with her various treatment options, including conservative care and

surgery.23 In Dr. Rubano’s view, conservative treatments such as injections, anti-

inflamatories, and physical therapy would not provide a long term solution.24

Conservative care also would not address Cline’s arthritis, her primary pain

generator.25 Similarly, arthroscopic surgery would only address pain from the

meniscal tear, whereas, a total knee replacement would address both the arthritis and

17
   Id.
18
   Id.
19
   Id.
20
   Id.
21
   Id.
22
   Id.
23
   Id. at 4.
24
   Id.
25
   Id.
                                           6
the meniscal tear and give Cline the best chance of full pain relief and of returning

to work in a timely fashion.26 After surgery, Cline returned to her job as a nurse

without restrictions.27

       Dr. Rubano acknowledged that he did not administer any conservative

treatment to Cline and that when Cline first visited him, he was not able to determine

whether the meniscal tear or the arthritis was the cause of her pain.28 Dr. Rubano

did dispute Dr. Schwartz’s opinion that the mechanism of Cline’s injury would not

have produced the fold slap tear of her medial meniscus.29 He explained that the

fold slap tear could not be dated and could have preexisted the work injury.30

       Cline testified as well. She testified she is 51 years old and works as a

pediatric nurse in the Pediatric Intensive Care Unit.31 She has been a nurse for almost

31 years and at Nemours for 14 years.32 She believes the patient who punched her

in the face and kicked her in the knee to be about 13 or 14 years old.33 She typically

works 12 hour shifts, mostly on her feet.34 Her job can be strenuous and requires

26
   Id.
27
   Id.
28
   Id.
29
   Id.
30
   Id.
31
   Id. at 5.
32
   Id.
33
   Id.
34
   Id.
                                          7
lifting.35 There are no light duty jobs available.36 She also teaches nursing as a side

job and watches her two year old granddaughter.37

         After her injury, she treated at Med Express for right knee pain. 38 She tried

to continue working, but eventually, her knee started to collapse, preventing her from

working.39 Between March 15, 2021 and April 9, 2021, she was on total disability.40

She self-treated with ice, Motrin, and rest.41 Light therapeutic exercises at home

only increased her pain.42 She was unable to stand for prolonged periods, sat in a

chair to cook and wash dishes, and relied on a seat when showering.43 Driving more

than 30 minutes was too painful and she stayed on the first floor of her house because

she was unable to use the stairs.44

         When she first saw Dr. Rubano, he discussed several treatment options,

including exercises, several types of injections, physical therapy, arthroscopic

surgery, and total knee replacement surgery.45 In discussing the treatment options,

he was of the opinion that neither conservative treatment, nor arthroscopic surgery

35
   Id.
36
   Id.
37
   Id.
38
   Id.
39
   Id.
40
   Id.
41
   Id.
42
   Id.
43
   Id.
44
   Id.
45
   Id.
                                            8
would help because they would not address her arthritis.46 She felt she needed to

return to full duty work because Nemours would replace her job if she was out four

to six months.47

       After discussing her options with her husband and doing additional online

research, she decided to proceed with a total knee replacement surgery because she

concluded that the more conservative options would not work or, in the case of

arthroscopic surgery, only be a temporary solution.48 She disputes a note in Dr.

Rubano’s records that a pre-surgical injection provided her with immediate pain

relief, testifying that she does not recall any relief from the injection.49 She

concluded that a total knee replacement would provide her with the greatest chance

of timely returning to work without restrictions.50

       Cline was able to return to work full time in August 2021 after surgery.51 She

was very happy with the full knee replacement surgery.52 Her knee feels amazing

and she was able to return to nearly all her activities of daily living, including

46
   Id. at 5-6.
47
   Id. at 6.
48
   Id.
49
   Id.
50
   Id.
51
   Id.
52
   Id.
                                          9
navigating stairs and running.53      While kneeling continues to be problematic,

otherwise, she essentially is pain free.54

       Dr. Schwartz testified by deposition for Nemours. Like Dr. Rubano, he is

board certified in orthopedic surgery and a certified provider under the Delaware

Workers’ Compensation Healthcare System.55 Although, unlike Dr. Rubano, he has

not performed a knee replacement surgery in 10 or 15 years.56 He examined Cline

on September 21, 2021.57 Dr. Schwartz questioned the causal relationship of the

replacement surgery to the injury, explaining that it would be unusual for a kick in

the knee by a pediatric patient to result in a significant meniscal tear.58 He further

believes that the mechanism of the injury would not have aggravated arthritis to

cause it to become symptomatic.59

       Apart from causation, Dr. Schwartz opined that total knee replacement

surgery was neither reasonable, nor necessary.60 In his view, the “rush” to surgery,

either arthroscopic or total replacement, did not comply with the Guidelines,

Medicare Guidelines, or Highmark of Delaware Guidelines because all three

53
   Id.
54
   Id.
55
   Id. at 6-7.
56
   Id.
57
   Id. at 7.
58
   Id.
59
   Id.
60
   Id.
                                             10
guidelines call for exhaustion of conservative treatment and documented

limitations.61 There was no evidence Cline had significant long term pain and no

documentation of how her quality of life was being limited.62

       Dr. Schwartz explained that conservative treatment includes nonsteroidal anti-

inflamatories, therapeutic injections such as Cortisone injections, supervised

physical therapy, muscle strength exercises, use of assistive devices, and weight

reduction, none of which Cline underwent.63 Merely talking about conservative

options, as appears to be the case here, is not sufficient to comply with the

Guidelines.64    Dr. Schwartz testified that it was very likely that conservative

treatment could return a person to a pre-injury level of function and activity.65 In his

opinion, Cline should have been given time to get well.66

       Dr. Schwartz further explained that Cline’s X-rays were essentially normal

and an April 2, 2021 MRI identified a medial meniscal tear, mild degenerative

changes, not apparent on the X-rays, a mild lateral patella tilt, and diffused left and

61
   Id.
62
   Id.
63
   Id.
64
   Id.
65
   Id. at 7-8.
66
   Id. at 8.
                                          11
50% thickness loss, none of which were significant.67 Total knee replacement

requires severe degenerative joint disease, which was not present here.68

       Dr. Schwartz acknowledged that Cline’s arthritis predated her work injury and

that it had been asymptomatic up until the injury.69 He also acknowledged that a

trauma could cause an asymptomatic condition to become symptomatic.70 On cross-

examination, Dr. Schwartz admitted that he did not review the films from the X-rays

or the MRI, only the reports.71 He was also unaware that there was a strict timeframe

for Cline to return to full-duty work to maintain her employment.72 Nor was he

aware that Cline had attempted to return to work before her surgery, but was unable

to do so because her knee gave out.73 Finally, Dr. Schwartz acknowledged that the

Guidelines are merely advisory and that treatment must be tailored to the individual

patient and not rendered to fit general scenarios.74

       Based on the totality of the evidence presented, the Board found that

proceeding to total knee replacement surgery without exhausting conservative care

was not reasonable or necessary.75 In doing so, it accepted the medical opinions of

67
   Id.
68
   Id.
69
   Id.
70
   Id.
71
   Id.
72
   Id. at 8-9.
73
   Id. at 9.
74
   Id.
75
   Id. at 10.
                                          12
Dr. Schwartz over those of Dr. Rubano.76 In particular, it accepted Dr. Schwartz’s

testimony that a “rush” to surgery would not comply with the Guidelines, the

Medicare Guidelines, or the Highmark of Delaware Guidelines because all three

guidelines call for “exhaustion of conservative treatment and documented

limitations.”77 The Board acknowledged that the Guidelines are merely guidelines,

but found that Cline should have pursued some type of conservative treatment first.78

       The Board concluded Dr. Rubano rushed the full knee replacement surgery.79

The Board was concerned that neither the reports from the X-rays, nor from the MRI

identified significant arthritis, yet Dr. Rubano testified that his review of the MRI

films identified moderate to severe arthritis.80 Further, his incorrect statement in his

medical records that Cline had exhausted conservative treatment when she had not

detracted from his credibility.81 Further, Dr. Rubano’s records did not sufficiently

support a diagnosis of severe degenerative joint disease, a requirement for total knee

replacement in Dr. Schwartz’s opinion.82 Finally, the Board appreciated Cline’s

76
   Id.
77
   Id.
78
   Id.
79
   Id.
80
   Id.
81
   Id.
82
   Id. at 10-11.
                                          13
need to return to full-duty work, but found that it was not reasonable or necessary to

rush to undergo a total knee replacement surgery.83

                     III.   THE PARTIES’ CONTENTIONS

      Cline contends that the Board’s decision should be reversed because the Board

committed legal error or abused its discretion and because its finding that her total

knee replacement surgery was not reasonable and necessary was not supported by

substantial evidence. First, Cline contends that the Board committed legal error

when it failed to address and apply the standards set forth in Brittingham v. St.

Michael’s Rectory.84 In particular, the Board failed to decide whether the treatment

was reasonable for Cline specifically by considering and analyzing various factors

including her age, prior surgical experience, general physical condition, likelihood

of success of the treatment, risk of worsening of the condition, or risk of death from

the offered treatment.85 Further, the Board incorrectly applied the standards set forth

in the Guidelines.86 The Board failed to give effect to the Guidelines’ statement that

services rendered by any Delaware workers’ compensation certified medical

provider, which Dr. Rubano is, “shall be presumed, in the absence of contrary

evidence, to be reasonable and necessary if such treatment and/or services conform

83
   Id.
84
   Op. Br. at 25 (citing Brittingham v. St. Michael’s Rectory, 788 A.2d 519 (Del.
2002), D.I. 13.
85
   Id. (citing Brittingham, at 524-25).
86
   Id. at 28.
                                           14
to the most current version of the Guidelines.”87 Deviations from the Guidelines

may be acceptable, however.88 The Guidelines specifically identify that total knee

replacement is reasonable when there is “severe osteoporosis and all reasonable

conservative measures have been exhausted and other reasonable surgical options

have been considered.”89 The Board incorrectly applied that standard when it held

the Guidelines require the “exhaustion of conservative treatment,” not the

exhaustion of all reasonable conservative measures as the Guidelines require.90

      Second, Cline contends that the Board’s conclusion that Cline’s total knee

replacement was not reasonable and necessary is not supported by substantial

evidence.91 Cline challenges the Board’s determination to accept the opinion of Dr.

Schwartz over that of Dr. Rubano.92 Specifically, she contends that Dr. Schwartz’s

opinion was invalid because it lacked a factual foundation93 and was contradictory

and inconsistent regarding Cline’s diagnosis and treatment.94 Finally, Dr. Rubano’s

opinion regarding Cline’s diagnostic films was uncontradicted.95

87
   Id. at 28-29 (quoting 19 Del. C. 2322C(6)).
88
   Id.
89
   Id. at 29 (quoting Delaware Healthcare Practice Guidelines, 19 Del. Admin. C. §
1342-7.4.5).
90
   Id.
91
   Id. at 32.
92
   Id. at 33-44.
93
   Id. at 34-38.
94
   Id., at 39-41.
95
   Id. at 41-43.
                                         15
      In response, Nemours argues that, although Brittingham, decided in 2002,

still is good law, more recent decisions make it clear that Brittingham is “to be a

factor in evaluating the reasonableness and necessity of treatment, rather than a

bright-line rule permitting claimants to choose their own course of treatment with

complete disregard of the established Guidelines.”96 Nemours contends that here it

is clear that Cline “jumped over” more conservative care options in an effort to return

to work as soon as possible, but, because she did not exhaust those conservative care

options, the Board acted within its legal authority in denying her petition for

additional compensation.97 Further, the Board’s decision was based on substantial

evidence in the form of Dr. Schwartz’s testimony that Cline’s rushed surgery was

not reasonable and necessary.98

                         IV.   STANDARD OF REVIEW

      The Board’s decision must be affirmed so long as it is supported by substantial

evidence and is free from legal error.99 Substantial evidence is that which a

reasonable mind might accept as adequate to support a conclusion.100 While a

96
   Answering Br. at15-16 (citing Nobles-Roark v. Burner, 2020 WL 4344551, at *2
(Del. Super. Ct. July 28, 2020)), D.I. 14.
97
   Id. at 16.
98
   Id. at 16-19.
99
   Conagra/Pilgrim’s Pride, Inc. v. Green, 2008 WL 2429113, at *2 (Del. June 17,
2008).
100
    Kelley v. Perdue Farms, 123 A.3d 150, 153 (Del. Super. 2015) (citing Person-
Gaines v. Pepco Holdings, Inc., 981 A.2d 1159, 1161 (Del. 2009)).
                                         16
preponderance of evidence is not necessary, substantial evidence means “more than

a mere scintilla.”101 Questions of law are reviewed de novo,102 but because the Court

does not weigh evidence, determine questions of credibility, or make its own factual

findings,103 it must uphold the decision of the Board unless the Court finds that the

Board’s decision “exceeds the bounds of reason given the circumstances.”104

                                V.     DISCUSSION

      The portion of the Board’s decision entitled “FINDINGS OF FACT AND

CONCLUSIONS OF LAW” consists of four paragraphs.105 It is in this section that

the Board sets out the legal standards it applied and the factual basis for its decision.

The first paragraph lays out the standard for an injury to be compensable as a work

related injury and the party bearing the burden of proof, neither of which are at issue

in this appeal.106 The remainder of the Board’s decision is reproduced below.

             When an employee has suffered a compensable injury, the
             employer is required to pay for reasonable and necessary
             medical services/treatment causally related to that injury.
             19 Del. C. §2322. What constitutes “reasonable medical
             services” for the purposes of Section 2322 is determined
             by the Board on a case-by-case basis. See Willey v. State,

101
    Breeding v. Contractors-One-Inc., 549 A.2d 1102, 1104 (Del. 1988).
102
    Kelley, 123 A.3d at 152–53 (citing Vincent v. E. Shore Markets, 970 A.2d 160,
163 (Del. 2009)).
103
    Bullock v. K-Mart Corp., 1995 WL 339025, at *2 (Del. Super. May 5, 1995)
(citing Johnson v. Chrysler Corp., 213 A.2d 64, 66–67 (Del. 1965)).
104
    Bromwell v. Chrysler LLC, 2010 WL 4513086, at *3 (Del. Super. Oct. 28, 2010)
(quoting Bolden v. Kraft Foods, 2005 WL 3526324, at *3 (Del. Dec. 21, 2005)).
105
    Cline, No. 1509418 at 9-12.
106
    Id. at 9.
                                        17
Del. Super., C.A. No. 85A-AP-16, Bifferato, J., 1985 WL
189319 at *2 (November 26, 1985). “Whether medical
services are necessary and reasonable or whether the
expenses are incurred to treat a condition causally related
to an industrial accident are purely factual issues within
the purview of the Board.” Bullock v. K-Mart
Corporation, Del. Super., C.A. No. 94A-02-002, 1995
WL 339025 at *3 (May 5, 1995).

Based on the entirety of the evidence incorporated herein,
the Board finds that proceeding to a total knee replacement
surgery without exhausting conservative care was not
reasonable or necessary. The Board accepts the medical
opinions of Dr. Schwartz over the medical opinions of Dr.
Rubano. Dr. Schwartz testified that such a rush to surgery
(whether total knee replacement surgery or arthroscopic
surgery) would not be compliant with the Practice
Guidelines, with the Medicare Guidelines or with the
Highmark of Delaware Guidelines. All three guidelines
call for exhaustion of conservative treatment and
documented limitations. While Practice Guidelines are
merely guidelines, the Board finds that Claimant should
have pursued some type of conservative treatment first. It
may have helped.

Dr. Rubano did present as rushing to a significant surgery.
Both doctors testified the X-rays were relatively normal.
The MRI report did not identify significant arthritis. Dr.
Rubano disputed the MRI report. He testified that when
he reviewed the MRI films, he identified moderate to
severe arthritis. It is concerning that the diagnostic reports
did not identify significant arthritic findings, yet Dr.
Rubano represented that there were. The Board would
have been interested to have heard Dr. Schwartz’s
interpretation of the MRI films. Dr. Rubano’s incorrect
statement in his medical records indicating Claimant had
exhausted conservative treatment when she did not,
detracted from Dr. Rubano’s credibility. His medical
records should have supported his opinion that
conservative treatment would not have been beneficial.
                             18
              Dr. Schwartz testified that total knee replacement requires
              severe degenerative joint disease – a finding the medical
              records did not sufficiently support.          The Board
              appreciates Claimant’s need to return to full-duty work but
              under this set of facts, the Board finds that it was not
              reasonable or necessary to rush to undergo a total knee
              replacement surgery. The Board denies Claimant’s
              Petition for Additional Compensation.107

      A. The Board’s Decision Was Not Free From Legal Error.

        In pressing her argument that the Board committed legal error or abused its

discretion, Cline first contends that the Board failed to correctly apply the Delaware

Supreme Court’s decision in Brittingham.108 In Brittingham, the claimant sustained

a compensable injury to her cervical spine during the course of her employment at

St. Michael’s Rectory.109 Brittingham sought treatment from a board certified

neurosurgeon who recommended cervical fusion surgery.110           She declined the

surgery because years before she had undergone neck surgery and did not want to

undergo similar surgery again.111 She attempted physical therapy, but discontinued

it when she could no longer tolerate the pain and continued with pain medication.112

After researching her medical options, Brittingham believed her history of smoking

and a diagnosed precursor condition to osteoporosis might affect the outcome of

107
    Id. at 9-11.
108
    Brittingham, 788 A.2d at 520.
109
    Id.
110
    Id.
111
    Id. at 520-21.
112
    Id. at 521.
                                          19
surgery requiring bone harvesting for fusion, such as the proposed surgery. 113 At

her employer’s request, she consulted with a board certified orthopedic surgeon who

specialized in spinal surgery as well as a neurosurgeon she chose.114 She determined

her options were two types of fusion surgery using different approaches or no

surgery with treatments to help her cope with her injury.115 She elected not to have

surgery and, as a result, her employer ultimately sought to terminate her total

disability benefits.116   It alleged that Brittingham had unreasonably refused to

undergo surgery and her refusal was the cause of her ongoing disability.117 The

Board determined that Brittingham had forfeited her right to total compensation by

refusing to undergo reasonable surgery.118 The Superior Court affirmed on appeal.119

      Resolving a split in Superior Court opinions regarding a claimant’s refusal of

medical treatment so as to forfeit compensation benefits, the Delaware Supreme

Court reversed.120 It found that the record in Brittingham’s case reflected the

complexity of variables that had to be factored into determining the reasonableness

of Brittingham’s refusal to have surgery.121 First was that the recommended surgical

113
    Id.
114
    Id.
115
    Id.
116
    Id.
117
    Id.
118
    Id. at 522.
119
    Id.
120
    Id. at 522-23.
121
    Id. at 524.
                                         20
procedure was major.122 Second was Brittingham’s physical condition as a smoker

with a precursor condition to osteoporosis.123 Third, the risks of surgery were

significant.124 Fourth, although all three surgeons predicted a high rate of success,

their perspective on a low risk of serious injury or death might be different from the

person undergoing the surgery.125 Fifth, Brittingham was not pleased with the results

of a prior surgical experience.126 Finally, two doctors, one from each side, who

appeared before the Board testified that it would be reasonable for Brittingham to

decline the surgery.127 Accordingly, the Supreme Court held that the reasonableness

of Brittingham’s refusal of her employer’s offer of reasonable medical care must be

considered by the Board.128 It was error to interpret the term “reasonable medical

treatment” objectively based on the treatment, and not subjectively based on the

claimant.129 The Board “must determine whether the treatment is reasonable for the

specific claimant and not whether the treatment is reasonable generally for anyone

with the claimant’s condition.”130

122
    Id.
123
    Id.
124
    Id.
125
    Id. at 525.
126
    Id.
127
    Id.
128
    Id. at 522.
129
    Id. at 523.
130
    Id.
                                         21
      Six years after Brittingham was decided, the Guidelines were adopted.131

“Services rendered by any health-care provider certified to provide treatment

services for employees shall be presumed, in the absence of contrary evidence, to be

reasonable and necessary if such treatment and/or services conform to the most

current version of the Delaware health-care practice guidelines.”132 With respect to

knee replacement surgery, such surgery is reasonable when there is “severe

osteoarthritis and all reasonable conservative measures have been exhausted and

other reasonable surgical options have been considered.”133

      Brittingham and the Guidelines are not in conflict, and, as Nemours

acknowledges, Brittingham still is good law.134 Consistent with Brittingham, then,

in making its factual determination as to the necessity and reasonableness of Cline’s

surgery, it is incumbent upon the Board to consider whether “all reasonable

conservative measures have been exhausted” as to Cline’s treatment specifically,

and not generally for anyone in her position.

      In the three relevant paragraphs of its Finding of Facts and Conclusions of

Law, the Board did not expressly apply that standard.135 At best, it alluded to a

requirement that it make its determination on a case-by-case basis, citing a case that

131
    Answering Br. at 14, D.I. 14.
132
    19 Del. C. § 2322C(6).
133
    19 Del. Admin. C. § 1342-7.4.5.
134
    Answering Br. at 15, D.I. 14.
135
    Cline, No. 1509418, at 9-11.
                                         22
was decided seventeen years before Brittingham.136 The only apparent consideration

the Board gave to Cline’s individual circumstances are three brief mentions at the

end of its decision.

         First, the Board referenced Dr. Schwartz’s testimony that the “rush to surgery”

was not compliant with various guidelines and found that “[Cline] should have

pursued some type of conservative treatment first. It may have helped.”137 Left

unsaid was any discussion of the conservative care Cline did receive – time, rest,

anti-inflammatory medication, and light therapeutic exercises. Also left unsaid was

any finding as to what type of additional conservative treatment specifically Cline

should have pursued or how that treatment might have helped her. A subjective

assessment of Cline’s individual care would have taken those considerations into

account. Perhaps the Board did do that, but its broad statement that “some type of

conservative treatment” “may have helped” does not convince the Court that it did.

         Then, the Board noted that Dr. Schwartz testified that the medical records

(presumably the X-ray and MRI reports) did not sufficiently support a diagnosis of

severe degenerative disease. At the same time, it stated that it would have been

interested in his interpretation of the actual MRI films. The Board did not explain

why it apparently was willing to discount Dr. Rubano’s testimony about what the

136
      Id. at 9-10.
137
      Id. at 10.
                                           23
actual films showed without having its interest in Dr. Schwartz’s interpretation of

those films satisfied.

         Finally, almost as an afterthought at the very end of its decision, the Board

writes that it “appreciates [Cline’s] need to timely return to full-duty work but under

this set of facts, the Board finds that it was not reasonable to rush to undergo a total

knee replacement surgery.”138 The Board did not explain how, or even if, it

considered Cline’s pressing need to return to full-duty work in its evaluation of the

reasonableness of her surgery.

         These three references, expressed in conclusory terms, are insufficient to

convince the Court that the Board examined Cline’s case subjectively. For example,

there is no indication in its decision that the Board considered Cline’s unsuccessful

conservative treatment, consisting of at-home exercises, rest, icing her knee, and

taking anti-inflammatory medication for weeks before her surgery, in determining

whether she had exhausted all reasonable conservative measures. Nor did it appear

to consider Cline’s testimony that light therapeutic exercises only increased her pain.

The Board did not discuss what effect, if any, Cline’s testimony that she was unable

to stand for prolonged periods, sat when cooking, washing dishes, and showering,

limited her driving to 30 minutes, and stayed on the first floor of her house because

she was unable to use the stairs in considering her limitations and the reasonableness

138
      Cline, No. 1509418, at 10-11.
                                           24
and necessity of her surgery. Additionally, the Board did not discuss Cline’s

unsuccessful attempt to return to work when her knee started to collapse or why it

discounted Cline’s need to return to work. It simply said in accepting the medical

testimony of Dr. Schwartz over that of Dr. Rubano that the “rush to surgery…was

not compliant with the Practice Guidelines, with the Medicare Guidelines or with

the Highmark of Delaware Guideline.”139

         Moreover, the Court is not confident that the Board correctly applied the

Guidelines. In order to find that the Board properly applied the Guidelines it must

find that the Board understood the Guidelines to require the exhaustion of all

reasonable conservative treatment.          The Board wrote in its decision that the

Guidelines “call for exhaustion of conservative treatment and documented

limitations.”140       In fact, the Guidelines do not call for the exhaustion of all

conservative measures, but only for the exhaustion of all reasonable conservative

measures. Perhaps the difference is semantical and of no significance, but perhaps

not. An excerpt from Dr. Rubano’s cross-examination brings this point into focus:

                         Q. So your operative note referencing an exhaustion
                   of conservative treatment is inaccurate; is that fair?

                        A. In this case I think the likelihood of other
                   conservative measures working was very low. So in this
                   case I think the conservative measures of giving it time

139
      Id. at 10.
140
      Id.
                                              25
               and taking off of work and anti-inflammatories, those, I
               believe were appropriate measures that were exhausted.

                        In my opinion, proceeding with the other
               conservative options, I don’t think they would have been
               successful.

                     Q. Doctor, I appreciate your opinion, Doctor, but
               I’m just talking about your note that she had exhausted
               conservative treatments. Did you prescribe physical
               therapy?

                      A. No.

                     Q. Okay. So is it fair to say that the universe of
               conservative therapy had not been exhausted at the time of
               the operation; is that fair?

                      A. That’s correct.141

         A reasonable interpretation of Dr. Rubano’s testimony is that he viewed all

reasonable conservative measures to have been exhausted since he did not think

other methods would work. Clearly, he did not exhaust the universe conservative

measures. So, when he referenced conservative measures being exhausted in his

operative note, was he referring to reasonable conservative measures? In other

words, was he using “conservative measures” as shorthand for “reasonable

conservative measures”?        The Board wrote that the Guidelines called for the

“exhaustion of conservative treatment.” When it used that phrase, did the Board

mean that the Guidelines called for the exhaustion of all reasonable conservative

141
      Dr. Rubano Tr. at 37:8–38:7, App. to Op. Br. at A-12, D.I. 13.
                                          26
treatment? If so, why was Dr. Rubano’s note not given the same interpretation by

the Board – that Cline exhausted all conservative treatment that was reasonable in

his opinion? It is not clear. The Board’s failure to discuss the conservative treatment

Cline did pursue and why that treatment did not exhaust all reasonable conservative

treatment leaves the issue of whether the Board properly applied the Guidelines in

doubt.

         Given all of the above, the Court cannot be confident that the Board applied

the correct standard in determining whether Cline had exhausted all reasonable

conservative treatment. In particular, the Court is not confident that the Board made

a subjective determination as to whether Cline exhausted all reasonable conservative

treatment suitable for her specifically, or whether it made an objective determination

as to treatment for people in her situation generally. Further, the Court is not

confident that the Board properly applied the Guidelines.

   B. The Board’s Factual Determination Was Not Supported By Substantial
       Evidence.

         The Court’s role on appeal is not to re-weigh the evidence and decide whether

the Board reached the correct decision. Instead, it is to decide whether there was

substantial evidence to support the Board’s decision and whether that decision was

free from legal error.      But, when the Board applies the wrong standard for

determining the reasonableness and necessity of Cline’s total knee replacement, it

runs the risk of failing to identify the substantial evidence supporting its decision.
                                           27
      After listening to the evidence, the Board found Dr. Schwartz’s medical

testimony more credible than Dr. Rubano’s testimony, which, of course, was within

its province to do. The problem for the Court on appeal is that the Board couched its

decision in such a conclusory fashion, that the Court is unable to identify the specific

facts it relied upon in deciding that Cline’s surgery was not necessary and

reasonable. The Board stated, “Based on the entirety of the evidence incorporated

herein, the Board finds that proceeding to total knee replacement surgery without

exhausting conservative care was not reasonable or necessary.142 No specific facts

were offered in support of that conclusion. Instead, the Board simply cited Dr.

Schwartz’s testimony that the “rush to surgery” did not comply with various

guidelines.143 This Court is tasked with determining whether the Board’s decision

is supported by substantial evidence. Rather than send the Court on a search of the

“entirety of the record” looking for substantial evidence, it would have been helpful

if the Board had undertaken that effort itself.

      Similarly, the Board resolved the dispute between the doctors over the extent

of Cline’s arthritis by discrediting Dr. Rubano’s reading of the actual MRI films in

favor of Dr. Schwartz’s testimony concerning an interpretive report of those films.144

It did so despite being “interested” in hearing Dr. Schwartz’s interpretation of the

142
    Cline, No. 1509418, at 10.
143
    Id.
144
    Id.
                                          28
films.145 The Board did not comment, either in its Summary of the Evidence or in

its Findings of Fact, on Dr. Rubano’s surgical observation that:

             [Cline] had advanced arthritis up underneath the kneecap,
             certainly worse than the report states. And then changes,
             significant changes on the medial and lateral
             compartments that would certainly justify the pain she was
             in. And not only proceeding with knee replacement, but
             further, in my mind, confirming that an arthroscopic
             procedure would not have addressed her problem.146

The Board explained that it favored Dr. Schwartz’s reading of the MRI report over

Dr. Rubano’s interpretation of the actual MRI films and his surgical observations

because of what it found to be an “incorrect” statement in Dr. Rubano’s medical

records regarding exhaustion of conservative care.147 But, interpreting diagnostic

films and making surgical observations are different than making an arguably

“incorrect” statement in a medical record. Concluding that Dr. Rubano’s actual

observations are to be discounted, especially when there is no on-point contradictory

testimony, on the basis of the Board’s interpretation of a comment Dr. Rubano made

in his medical records regarding exhaustion of conservative care is curious.148 In the

Court’s view, a better explanation is required.

145
    Id.
146
    Dr. Rubano Tr. at 22:22-23:8, App. to Op. Br. at A-8, D.I. 13.
147
    Cline, No. 1509418, at 10.
148
    See the Court’s discussion of Dr. Rubano’s testimony regarding exhaustion of
conservative treatment, supra.
                                         29
      There may be substantial evidence in the record to support the Board’s

decision, but the Board failed to identify that evidence sufficiently and explain why

it supports the Board’s decision. Accordingly, the Court cannot conclude that the

Board’s decision is supported by substantial evidence.

                                   VI. CONCLUSION

      For the foregoing reasons, the Court is unable to conclude that the Board’s

decision was free from legal error and was supported by substantial evidence.

Therefore, the Board’s decision is REVERSED and REMANDED to the Industrial

Accident Board for further proceedings consistent with this Opinion.

IT IS SO ORDERED.

                                              /s/ Ferris W. Wharton
                                               Ferris W. Wharton, J.

                                         30