B.B. and Defense Agencies, Education Activities, Fort Bragg, NC (Board decision, April 25, 2016)

ECAB final decision. The Board affirmed OWCP’s June 15, 2015 denial of B.B.’s injury claim. It separately directed OWCP to address payment for treatment authorized by a Form CA-16, which does not depend on acceptance of the claim. Under 20 C.F.R. § 501.6(d), this Board decision becomes final 30 days after issuance unless the Board fixed a different period in it. A party may petition the Board for reconsideration within 30 days unless this decision specifies another period, under 20 C.F.R. § 501.7(a). FECA compensation decisions are generally not subject to court review under 5 U.S.C. § 8128(b).

Plain-English summary

B.B., an educational aide, fell in a classroom after a student grabbed her arm. OWCP accepted that the incident occurred but denied her injury claim. The Board found that the treating doctors had checked boxes linking her symptoms and diagnoses to the fall without explaining how it caused a diagnosed condition. Imaging reports identified spinal findings but did not address their cause. The Board affirmed the claim denial and asked OWCP to address whether it had paid for treatment authorized by the employer’s Form CA-16.

Decision snapshot

• Authority: FECA traumatic injury and medical causation requirements; 20 C.F.R. § 10.300(c) on Form CA-16 treatment.
• Outcome: June 15, 2015 injury claim denial affirmed; Form CA-16 payment issue left for OWCP.
• Key point: An accepted incident and medical diagnoses did not establish a compensable injury without a reasoned medical link.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
B.B., Appellant
)
)
and ) Docket No. 16-0262
) Issued: April 25, 2016
DEFENSE AGENCIES, EDUCATION
)
ACTIVITIES, Fort Bragg, NC, Employer
)
__________ )

Appearances: Case Submitted on the Record
Appellant, pro se
Office of Solicitor, for the Director

DECISION AND ORDER

Before:
CHRISTOPHER J. GODFREY, Chief Judge
ALEC J. KOROMILAS, Alternate Judge
VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On November 24, 2015 appellant filed a timely appeal from a June 15, 2015 merit decision of the Office of Workers’ Compensation Programs (OWCP). Pursuant to the Federal Employees’ Compensation Act1 (FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over the merits of this case.

ISSUE

The issue is whether appellant met her burden of proof to establish a traumatic injury causally related to the accepted October 30, 2014 employment incident.

FACTUAL HISTORY

On November 5, 2014 appellant, then a 36-year-old educational aide, filed a traumatic injury claim (Form CA-1) alleging that on October 30, 2014 she sustained left hip, neck, and lower back pain when she lost her balance and fell down onto her left side after a student

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5 U.S.C. § 8101 et seq. grabbed her left arm. She stopped work on October 30, 2014 and returned to work on January 5, 2015.

An accident and injury report from the employing establishment dated October 30, 2014 confirmed that on October 30, 2014 a student was “having a melt down and pulled [appellant’s] arm causing her to fall.” Appellant related that she experienced pain and spasms in her left lower back and numbness in her left lower extremity.

Appellant also submitted an authorization for examination and/or treatment (Form CA- 16), dated October 30, 2014 and signed by a supervisor. She recounted that on October 30, 2014 a student grabbed her left arm, which caused her to fall down and land on her left side. The physician’s portion of the form was completed by Dr. Ismael Flores-Santiago, a Board-certified internist. He described the October 30, 2014 work incident and related that appellant had pain on the left side of her neck, lateral aspect of the left hip, and pain in the lumbosacral region. Dr. Flores-Santiago diagnosed neck pain, lower back pain, and lumbar radiculopathy. He checked a box marked “yes” that appellant’s condition was caused or aggravated by the described employment activity. Dr. Flores-Santiago noted that appellant was totally disabled from November 4 to 12, 2014 and could resume light duty beginning November 13, 2014. He also provided discharge instructions for appellant.

Appellant submitted another Form CA-16 signed by an emergency physician with an illegible signature who related that on October 30, 2014 a student became upset in her class, grabbed her left arm, and caused her to fall down onto her left side. He marked “yes” that appellant’s condition was caused or aggravated by the described employment activity. The physician noted that she was unable to resume work until she was treated by her primary physician.

Appellant was also treated by Dr. Mark Hooste, a Board-certified family practitioner, who noted in attending physician reports dated December 11, 2014 and January 13, 2015 the history of injury and reported findings of neck stiffness, back pain, and left hip pain. Dr. Hooste diagnosed neck pain, lower back pain, and lumbar radiculopathy. He checked a box marked “yes” that appellant’s condition was caused or aggravated by the described employment activity. Dr. Hooste indicated that she was totally disabled from November 4, 2014 to January 2, 2015 and partially disabled from January 3 to March 1, 2015.

By letter dated May 13, 2015, OWCP advised appellant that the evidence submitted was insufficient to establish her claim. It requested additional medical evidence to demonstrate that she sustained a diagnosed condition causally related to the employment incident. Thereafter, on May 20, 2015 OWCP received additional medical reports.

In an October 30, 2014 radiology examination report, Dr. Michael J. Walden, a Board- certified diagnostic radiologist who specializes in neuroradiology, related that appellant fell down on her left side and now complained of left hip pain. He reported that the examination demonstrated no evidence of significant traumatic, arthritic, or inflammatory changes.

Appellant underwent another diagnostic examination by Dr. Craig S. Labuda, a Board- certified family practitioner and diagnostic radiologist, who indicated in a November 5, 2014

2 radiology report that her lumbar and cervical spine demonstrated L5-S1 disc space narrowing and small endplate osteophytes at C4 and C5. Dr. Labuda reported that there was no spondylolysis or spondylolisthesis of the lumbar spine.

Appellant continued to receive treatment from Dr. Flores-Santiago, who reported on November 14, 2014 findings of neck pain, low back pain, and left leg pain and diagnosed neck pain, low back pain, and lumbar radiculopathy. Dr. Flores-Santiago marked a box “yes” that her condition was caused or contributed by the described employment activity. He prescribed medications and recommended physical therapy. Dr. Flores-Santiago indicated that appellant was totally disabled from November 4 to December 15, 2014.

In a November 14, 2014 magnetic resonance imaging scan examination report of the lumbar spine, Dr. Kenneth A. Griggs, a Board-certified diagnostic radiologist, recounted that appellant had an accident at work when she fell down on her left side and complained of pain in the low lumbar spine. He observed spondylotic changes of the lumbar spine, most notable at L4- 5 and L5-S1 with a small left paracentral disc protrusion.

On December 2, 2014 appellant began physical therapy treatment.

On May 20, 2015 Douglas Bowker, the employing establishment human resource specialist, informed OWCP in a letter that appellant provided several documents in response to OWCP’s development letter. He noted that based on the medical evidence, the employing establishment believed that she had established that the condition of lumbar radiculopathy was causally related to the October 30, 2014 employment injury.

In a decision dated June 15, 2015, OWCP denied appellant’s claim. It accepted that the October 30, 2014 employment incident occurred as described but denied the claim as the medical evidence of record was insufficient to establish that she sustained a diagnosed condition as a result of the accepted incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA2 has the burden of proof to establish the essential elements of his or her claim by the weight of the reliable, probative, and substantial evidence3 including that he or she sustained an injury in the performance of duty and that any specific condition or disability for work for which he or she claims compensation is causally related to that employment injury.4

To determine whether a federal employee has sustained a traumatic injury in the performance of duty, it first must be determined whether “fact of injury” has been established.5

2
Id.
3
J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968).
4
G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989).
5
S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005).

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There are two components involved in establishing the fact of injury. First, the employee must submit sufficient evidence to establish that she actually experienced the employment incident at the time, place, and in the manner alleged.6 Second, the employee must submit evidence, generally only in the form of probative medical evidence, to establish that the employment incident caused a personal injury.7 An employee may establish that the employment incident occurred as alleged, but fail to show that his or her disability or condition relates to the employment incident.8

The opinion of the physician must be based on a complete factual and medical background of the employee, must be one of reasonable medical certainty, and must be supported by medical rationale explaining the nature of the relationship between the diagnosed condition and the specific employment factors identified by the employee.9 The weight of the medical evidence is determined by its reliability, its probative value, its convincing quality, the care of analysis manifested, and the medical rationale expressed in support of the physician’s opinion.10

ANALYSIS

OWCP accepted that on October 30, 2014 appellant experienced pain in her left hip, neck, and lower back when she lost her balance and fell down on her left side after a student grabbed her left arm in a classroom. It denied her claim as she did not submit rationalized, probative medical evidence to establish that the October 30, 2014 incident caused or contributed to a diagnosed medical condition. The Board finds that appellant has not met her burden of proof to establish that she sustained an injury on October 30, 2014 causally related to the accepted incident.

Appellant submitted various attending physician reports dated October 30, 2014 to January 13, 2015 by Drs. Flores-Santiago and Hooste in which they accurately described the October 30, 2014 work incident and related her complaints of pain on the left side of her neck, hip, and lumbar area. They reported findings of neck pain, low back pain, and left leg pain and provided diagnoses of neck pain, low back pain, and lumbar radiculopathy. Drs. Flores-Santiago and Hooste both marked boxes “yes” that the diagnosed conditions were causally related to the described employment activity. The Board has held, however, that when a physician’s opinion on causal relationship consists only of checking “yes” to a form question, without explanation or rationale, that opinion is of diminished probative value and is insufficient to establish a claim.11 These reports offered no rationalized medical explanation explaining how the accepted fall on

6
Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968).
7
David Apgar, 57 ECAB 137 (2005); John J. Carlone, 41 ECAB 354 (1989).
8
T.H., 59 ECAB 388 (2008); see also Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006).
9
I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 465 (2005).
10
James Mack, 43 ECAB 321 (1991).
11
D.D., 57 ECAB 734, 738 (2006); Deborah L. Beatty, 54 ECAB 340 (2003).

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October 30, 2014 caused a diagnosed condition.12 The reports, therefore, failed to establish that appellant sustained a traumatic injury as a result of the October 30, 2014 employment incident.

In diagnostic reports dated October 30, and November 5 and 14, 2014, Drs. Walden, Labuda, and Griggs observed L5-S1 disc space narrowing, small endplate osteophytes at C4 and C5, and spondylotic changes of the lumbar spine. Although the physicians provided medical diagnoses, none of the physicians provided any opinion on the cause of appellant’s conditions nor an explanation on whether the October 30, 2014 employment incident caused or contributed to the diagnosed conditions. The Board has found that medical evidence that does not offer any opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal relationship.13 Because these diagnostic reports do not establish a causal relationship between the October 30, 2014 employment incident and appellant’s alleged conditions, they are insufficient to establish appellant’s traumatic injury claim.

The additional October 30, 2014 attending physician’s report from an emergency physician with an illegible signature also fails to establish causal relationship because reports that are unsigned or that bear illegible signatures cannot be considered probative medical evidence because they lack proper identification.14

On appeal, appellant alleges that there was substantial medical documentation to establish that she had lumbar radiculopathy from her injury. She asserted that an OWCP claims examiner “went beyond their scope” and made a decision based on personal opinion instead of the doctors’ opinions. As explained above, however, the medical documents that appellant submitted fail to establish that she sustained a work-related injury on October 30, 2014. The issue of causal relationship is a medical question that must be established by probative medical opinion from a physician.15 Appellant did not provide a rationalized medical opinion based on an accurate background which described or explained the medical process through which the October 30, 2014 could have caused her alleged injuries. Accordingly, she did not establish that she sustained an injury in the performance of duty and failed to meet her burden of proof.

The Board notes that the employing establishment issued a CA-16 form authorization for medical treatment on October 30, 2014. Where an employing establishment properly executes a Form CA-16, which authorizes medical treatment as a result an employee’s claim for an employment-related injury, the Form CA-16 creates a contractual obligation, which does not involve the employee directly, to pay for the cost of the examination or treatment regardless of the action taken on the claim.16 The period for which treatment is authorized by a Form CA-16 is limited to 60 days from the date of issuance, unless terminated earlier by OWCP.17 In this 12 See D.G., 15-0948 (issued February 10, 2016).
13
R.E., Docket No. 10-679 (issued November 16, 2010); K.W., 59 ECAB 271 (2007).
14
Thomas L. Agee, 56 ECAB 465 (2005); Richard F. Williams, 55 ECAB 343 (2004).
15
W.W., Docket No. 09-1619 (June 2, 2010); David Apgar, 57 ECAB 137 (2005).
16
A.B., Docket No. 15-1002 (issued August 14, 2015); Tracey P. Spillane, 54 ECAB 608 (2003).
17
20 C.F.R. § 10.300(c).

5 case, it is unclear whether OWCP paid for the cost of appellant’s examinations. On return of the case record, OWCP should further address the issue.18

Appellant may submit new evidence or argument with a written request for reconsideration to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128(a) and 20 C.F.R. §§ 10.605 through 10.607.

CONCLUSION

The Board finds that appellant did not meet her burden of proof to establish a traumatic injury causally related to the accepted October 30, 2014 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the June 15, 2015 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: April 25, 2016
Washington, DC

Christopher J. Godfrey, Chief Judge
Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge
Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge Employees’ Compensation Appeals Board

18
Supra note 16.

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