Court Opinion

ID: 9401782
Source: CourtListenerOpinion
Date Created: 2023-06-13 22:13:33.941097+00
Date Added: 2024-06-11T17:19:55.222185
License: Public Domain

FILED
                                                                                June 13, 2023
                                                                              EDYTHE NASH GAISER, CLERK
                                                                              SUPREME COURT OF APPEALS
                                                                                  OF WEST VIRGINIA

                                STATE OF WEST VIRGINIA
                              SUPREME COURT OF APPEALS

West Virginia Office of the Insurance Commissioner,
Commissioner Below, Petitioner

and

RNG Service, Co.
Employer Below, Petitioner

vs.)     No. 21-0811 (BOR Appeal No. 2057070)
                       (Claim No. 900054070)

Jeffrey J. Johns,
Claimant Below, Respondent

                                 MEMORANDUM DECISION

       Petitioner West Virginia Office of the Insurance Commissioner (“WVOIC”), in its capacity
as administrator of The Old Fund, and RNG Service Company, appeal the order of the West
Virginia Workers’ Compensation Board of Review (“Board of Review”) dated September 22,
2021. The Board of Review reversed and vacated the June 16, 2021, decision of the Workers’
Compensation Office of Judges (“Office of Judges”) affirming the claims administrator’s order of
November 28, 2018, denying Respondent Jeffrey J. John’s request for left knee arthroscopic
surgery. 1 Upon our review, we determine that oral argument is unnecessary and that a
memorandum decision affirming the Board of Review’s order is appropriate. See W. Va. R. App.
P. 21.

         Mr. Johns sustained a compensable injury on April 9, 1990, when he was working on a gas
line which exploded. He was knocked unconscious and transported to Ruby Memorial Hospital
with injuries to his left leg and a laceration to his liver. The claim was held compensable for closed
femur shaft fracture. Due to the severity of his injury, Mr. Johns underwent a left reduction of the
left knee dislocation with open reduction internal fixation of medial malleolus and placement of a
distal lock intramedullary rod in the left femur. On March 2, 1991, he had a reconstruction of his
anterior cruciate ligament. Mr. Johns was able to return to work as an auto parts salesman in 1993
before becoming a maintenance worker for the Department of Highways in 1996.

         1
             WVOIC is represented by Melissa M. Stickler. A response was not filed on behalf of Mr.
Johns.
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       The record indicates that Mr. Johns has undergone extensive therapy for his left leg and
wore a left knee brace for several years. In 2000, Mr. Johns started seeing Lucas Pavlovich, M.D.,
because of persistent symptoms such as pain and swelling in his left knee. He was initially treated
with medication and steroid injections for his pain. However, he eventually underwent
chondroplasty and a partial lateral meniscectomy in October of 2003.

        On July 1, 2004, Joseph Grady, M.D., performed an independent medical evaluation of Mr.
Johns’s compensable injury. Dr. Grady noted that he continued to have problems with his left knee
following the initial surgery, and he later underwent left knee chondroplasty and a partial lateral
meniscectomy in October 2003. Mr. Johns was informed that he probably needed surgery for an
injury to his posterior cruciate ligament, but he opted not to pursue surgery. Based upon his
physical examination and a review of the available medical records, Dr. Grady found Mr. Johns to
be at maximum medical improvement with a total of 18% whole person impairment for his
compensable injuries.

        In a clinical encounter summary dated July 15, 2014, Dr. Pavlovich noted that Mr. Johns
reported to his office with a new injury to his right knee. Mr. Johns stated that he twisted his right
knee stepping out of a grader on July 8, 2014, and he experienced popping and burning sensations
along the medial aspect of his right knee at the time of the injury. He later developed difficulty
bearing weight and medial discomfort. Dr. Pavlovich’s assessment was right knee internal
derangement with possible medial meniscus tear versus articular cartilage injury. An MRI of the
right knee was recommended.

        On June 8, 2018, Mr. Johns returned to Dr. Pavlovich and reported a sudden onset of left
knee pain and effusion. The symptoms occurred unexpectedly and were not related to a specific
event or activity. Mr. Johns reported that he was doing well until the recent onset of pain and
swelling. He was unable to work due to his left knee symptoms and using crutches to walk. Dr.
Pavlovich examined Mr. Johns and observed severe guarding of the left knee and tenderness to
light touch. There was large effusion over the left knee compared to the right knee. Dr. Pavlovich’s
assessment was left knee internal derangement and effusion. He was treated with left knee
aspiration and injections.

        Mr. Johns followed-up with Dr. Pavlovich on June 19, 2018, reporting an onset of sharp
pain, effusion, and mechanical catching in his left knee. Dr. Pavlovich noted that, “(h)e states that
a week and a half ago he twisted his knee and felt immediate sharp pain and developed a large
effusion.” Mr. Johns had just completed a course of Supartz and started to see some relief with his
injections. However, once he irritated his knee, he experienced swelling. Mr. Johns had the
effusion aspirated, and he received a cortisone injection. Because Mr. Johns had sharp pain on the
medial side of his knee, Dr. Pavlovich believed he may have a medial meniscus tear and wished
to proceed with a diagnostic arthroscopy. In a protestable Order dated November 28, 2018, the
claims administrator denied Dr. Pavlovich’s request for left knee arthroscopy. The claims
administrator stated that the reason for the denial was, “[I]t appears to be a new injury; this is not
compensable to the 04/09/1990 work injury.” Mr. Johns protested the claims administrator’s
decision.

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       In a letter dated December 15, 2018, Dr. Pavlovich notified the claims administrator that
he was requesting knee arthroscopy for determining whether Mr. Johns had a medial meniscal tear.
Dr. Pavlovich stated:

       “He has had a previous knee reconstruction and has had instability as a result of his
       ligamentous injury. He reinjured his knee and aggravated his condition. As a result
       of his aggravation of his previous condition from 1990, I request that he proceed
       with a diagnostic arthroscopy.”

Additional medical records from Dr. Pavlovich dated February 13, 2019, noted that Mr. Johns
denied any new injuries, but indicated that his left knee pain and swelling had increased. Physical
examination revealed left knee range of motion to 130 degrees and hypersensitivity over the
peroneal nerve and the medial and lateral joint line. Dr. Pavlovich’s assessment was left knee
internal derangement with likely chondral and meniscal pathology. It was opined that Mr. Johns’s
left knee problems were causally related to his initial workers’ compensation injury of April 9,
1990, in the form of a progressive deterioration of the knee. Dr. Pavlovich stated that Mr. Johns
would benefit from either diagnostic arthroscopy or another round of cortisone and hyaluronic acid
injections. Because Mr. Johns had recently received cortisone injections, Dr. Pavlovich
recommended left knee arthroscopy as it appeared that the results of the injections had plateaued.

        In a final decision dated June 16, 2021, the Office of Judges affirmed the claims
administrator’s November 28, 2018, decision and held that the weight of the evidence does not
establish that the request for left knee arthroscopy is medically necessary and reasonably related
to Mr. Johns’s compensable left knee injury of April 9, 1990. The Office of Judges concluded that
the record indicates that Dr. Pavlovich’s request for left knee arthroscopy was precipitated by a
sudden onset of left knee symptoms following a new injury in 2018. As such, the Office of Judges
found that Mr. Johns failed to show that the request for left knee arthroscopy is reasonably related
to the compensable injury of April 9, 1990.

        On September 22, 2021, the Board of Review reversed and vacated the final decision of
the Office of Judges dated June 16, 2021. The Board of Review found the analysis and conclusions
of the Office of Judges to be clearly wrong in view of the reliable, probative, and substantial
evidence on the whole record. Specifically, the Board of Review found that Dr. Pavlovich opined
that Mr. Johns’s knee condition is related to his initial injury as a progressive deterioration of the
knee. After noting Mr. Johns’s multiple injuries to his left knee in a gas line explosion on April 9,
1990, the Board of Review stated:

       Lucas Pavlovich, M.D., has treated the claimant’s left knee for many years. On June
       8, 2018, Dr. Pavlovich reported that yesterday the claimant’s left knee started to
       have a large effusion and a severe amount of pain. Dr. Pavlovich aspirated the knee
       and gave the claimant an injection. On June 19, 2018, Dr. Pavlovich reported that
       the claimant stated he twisted his knee a week and half ago. On December 15, 2018,
       Dr. Pavlovich said the claimant had a previous knee reconstruction and has had
       instability as a result of his ligamentous injury. Dr. Pavlovich said he requested a
       diagnostic arthroscopy as a result of the claimant’s aggravation of his previous
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       condition from 1990. On February 13, 2019 (in the electronic claim file under date
       of June 8, 2018), Dr. Pavlovich indicated that the claimant has had numerous
       surgeries related to his Workers’ Compensation claim, he had had no new injury,
       and his pain and swelling have recently worsened. Dr. Pavlovich opined that the
       knee condition is related to the claimant’s initial Workers’ Compensation claim and
       this is progressive deterioration of the knee. He recommended a knee arthroscopy.

The Board of Review concluded that the claims administrator has authorized Mr. Johns to have at
least six surgeries involving the left knee, and the only medical evidence in the record relating to
the need for an arthroscopic surgery is from Dr. Pavlovich. Finally, the Board of Review concluded
that Dr. Pavlovich’s reports establish that left knee arthroscopic surgery is medically necessary
and reasonably required in the course of treatment for Mr. Johns’s compensable injury.

        This Court may not reweigh the evidentiary record, but must give deference to the findings,
reasoning, and conclusions of the Board of Review, and when the Board’s decision effectively
represents a reversal of a prior ruling of either the Workers’ Compensation Commission or the
Office of Judges, we may reverse or modify that decision only if it is in clear violation of
constitutional or statutory provisions, is clearly the result of erroneous conclusions of law, or is so
clearly wrong based upon the evidentiary record that even when all inferences are resolved in favor
of the Board’s findings, reasoning, and conclusions, there is insufficient support to sustain the
decision. See W. Va. Code § 23-5-15(c) & (e). We apply a de novo standard of review to questions
of law. See Justice v. W. Va. Off. of Ins. Comm’r, 230 W. Va. 80, 83, 736 S.E.2d 80, 83 (2012).
        After review, we agree with the findings and conclusions of the Board of Review. Although
the Office of Judges determined that Mr. Johns was found to be at his maximum degree of medical
improvement for the compensable injury in 2004, Dr. Pavlovich requested diagnostic knee
arthroscopy due to an aggravation of his previous condition. Dr. Pavlovich stated in his December
15, 2018, letter, that Mr. Johns has had previous knee reconstruction and has had instability as a
result of his ligamentous injury. Dr. Pavlovich then concluded that Mr. Johns reinjured his knee
and aggravated his condition. As such, Mr. Johns has established that the request for left knee
arthroscopic surgery is medically necessary and reasonably required to treat his compensable
injury, as required by West Virginia Code § 23-4-3 and West Virginia Code of State Rules § 85-
20.
                                                                                            Affirmed.

ISSUED: June 13, 2023

CONCURRED IN BY:
Chief Justice Elizabeth D. Walker
Justice Tim Armstead
Justice John A. Hutchison
Justice William R. Wooton
Justice C. Haley Bunn

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