J.M. and U.S. Postal Service, Staten Island Post Office, Staten Island, NY (Board decision, September 29, 2020)

ECAB final decision. May 15, 2019 claim denial affirmed. A party may petition the Board for reconsideration within 30 days of issuance unless this decision specifies another period, under 20 C.F.R. § 501.7(a).

Plain-English summary

J.M., a postal clerk, reported neck, shoulder, and arm symptoms after lifting a metal registry cage window at work. Although OWCP accepted the lifting incident, the Board found that the medical reports did not adequately explain how it caused the diagnosed conditions. It affirmed OWCP’s May 15, 2019 injury claim denial.

Decision snapshot

• Authority: FECA medical causation requirement for a traumatic injury claim.
• Outcome: May 15, 2019 claim denial affirmed.
• Key point: The accepted lifting incident lacked a sufficiently reasoned medical causal link.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
J.M., Appellant
)
)
and ) Docket No. 20-0256
) Issued: September 29, 2020
U.S. POSTAL SERVICE, STATEN ISLAND
)
POST OFFICE, Staten Island, NY, Employer
)
__________ )

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

DECISION AND ORDER

Before:
ALEC J. KOROMILAS, Chief Judge
CHRISTOPHER J. GODFREY, Deputy Chief Judge PATRICIA H. FITZGERALD, Alternate Judge

JURISDICTION

On November 12, 2019 appellant filed a timely appeal from a May 15, 2019 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.2

ISSUE

The issue is whether appellant has met her burden of proof to establish a medical condition causally related to the accepted March 13, 2019 employment incident.

1
5 U.S.C. § 8101 et seq.
2
The record provided to the Board includes evidence received after OWCP issued its May 15, 2019 decision.
However, the Board’s Rules of Procedure provides: “The Board’s review of a case is limited to the evidence in the case record that was before OWCP at the time of its final decision. Evidence not before OWCP will not be considered by the Board for the first time on appeal.” 20 C.F.R. § 501.2(c)(1). Thus, the Board is precluded from reviewing this additional evidence for the first time on appeal. Id.

FACTUAL HISTORY

On March 14, 2019 appellant, then a 47-year-old clerk, filed a traumatic injury claim (Form CA-1) alleging that on March 13, 2019 she felt pain in her right shoulder, arm, and neck when lifting a metal registry cage window while in the performance of duty. She stopped work on March 14, 2019.

A March 14, 2019 medical report with an unidentifiable signature, noted that appellant was seen that day and could not return to work until March 28, 2019 due to her injury.

In correspondence dated March 18, 2019, D.L., a manager with the employing establishment, noted that appellant immediately reported the March 13, 2019 employment incident, but initially declined medical treatment. He indicated that she sought medical treatment when she returned to work the next day.

In a March 26, 2019 work status report, Dr. Syed Husain, Board-certified in pain medicine, diagnosed cervical radiculopathy and noted that appellant could not return to work until further evaluation. In a duty status report (Form CA-17) of even date, an unidentifiable healthcare provider diagnosed cervical radiculopathy as a result of “lifting a metal window gate” and found that appellant was unable to perform her regular work duties.

A March 27, 2019 magnetic resonance imaging (MRI) scan of the cervical spine revealed spondylosis with bilateral foraminal narrowing at C5-8 and disc osteophyte complex with moderate left neural foramnal narrowing and moderate right neutral forminal narrowing at C6-7.

In a March 28, 2019 request for medical documentation, Dr. Husain was asked to provide a medical report including his medical findings and all diagnoses and address causal relationship. He was also provided a work capacity evaluation (Form OWCP-5C) for his completion.

In a March 29, 2019 work status report, Dr. Husain diagnosed cervical radiculopathy and spondylosis with radiculopathy. He held appellant off work until further evaluation.

A continuation of pay (COP) nurse report dated April 4, 2019 indicated that appellant remained off work because of the reported injury to the neck and right shoulder as a result of lifting a window gate of the registry cage.

In an April 5, 2019 report, Dr. Husain noted that appellant presented following a March 13, 2019 workplace injury, with complaints of radiating neck pain and tingling and numbness. He found muscle tenderness, back and neck pain, and neck stiffness on examination and noted cervical and right shoulder MRI scan findings. Dr. Husain diagnosed cervical radiculopathy, cervical spondylosis with radiculopathy, and incomplete right shoulder rotator cuff tear/rupture.

On April 8, 2019 Dr. Husain submitted a general medical and surgical authorization request for a cervical spinal injection. He reiterated his prior diagnoses.

In an April 12, 2019 development letter, OWCP informed appellant of the deficiencies in her claim. It informed her of the type of medical evidence necessary to establish her claim. OWCP afforded appellant 30 days to submit the necessary evidence.

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In a March 26, 2019 medical report, Dr. Husain noted that appellant presented with cervical spine and right shoulder pain, causing pain in her right ear. Appellant noted that she felt pain instantly when “lifting a metal gate” while at work on March 13, 2019. She also noted that her pain radiated down the entire right arm and that she was experiencing numbness and tingling. Dr. Husain reviewed x-rays of the cervical spine and right shoulder, which were negative, and noted that appellant had no prior history of injury. He indicated that her injury was work related and resulted from a strain. On physical examination, Dr. Husain noted that she had muscle tenderness, back and neck pain, and neck stiffness, as well as swelling in ankles and legs. He diagnosed cervical radiculopathy and performed a trigger point injection into appellant’s cervical paraspinal and trapezius muscles.

In a March 29, 2019 medical report, Dr. Husain reiterated appellant’s history of injury, noted the March 27, 2019 cervical spine MRI scan findings, and diagnosed cervical radiculopathy, cervical spondylosis with radiculopathy, and incomplete right shoulder rotator cuff tear/rupture. He recommended epidural injections.

An April 1, 2019 right shoulder MRI scan revealed mild tendinosis and peritendinitis of the anterior distal supraspinatus tendon and mild arthropathy of the acromioclavicular joint with a periarticular osseous reaction.

In an April 4, 2019 medical report, Dr. Husain reiterated appellant’s history of injury and the prior diagnoses. He noted that her neck pain and tingling had improved while her shoulder pain had worsened. He reported that she was still not working.

In an April 5, 2019 work status report, Dr. Husain again noted his prior diagnoses and indicated that appellant was unable to return to work at that time.

By decision dated May 15, 2019, OWCP denied appellant’s traumatic injury claim finding that the medical evidence submitted was insufficient to establish causal relationship between her diagnosed conditions and the accepted March 13, 2019 employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA3 has the burden of proof to establish the essential elements of his or her claim, including that the individual is an employee of the United States within the meaning of FECA, that the claim was timely filed within the applicable time limitation of FECA,4 that an injury was sustained in the performance of duty as alleged, and that any disability or medical condition for which compensation is claimed is causally related to the

3
Supra note 1.
4
F.H., Docket No. 18-0869 (issued January 29, 2020); J.P., Docket No. 19-0129 (issued April 26, 2019); Joe D.
Cameron, 41 ECAB 153 (1989).

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employment injury.5 These are the essential elements of each and every compensation claim, regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.6

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. There are two components involved in establishing fact of injury. First, the employee must submit sufficient evidence to establish that he or she actually experienced the employment incident at the time, place, and in the manner alleged. The second component is whether the employment incident caused a personal injury and can be established only by medical evidence.7

The medical evidence required to establish causal relationship between a claimed condition and an employment incident is rationalized medical opinion evidence.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 specific employment factors identified by the employee.9

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish a medical condition causally related to the accepted March 13, 2019 employment incident.

In medical reports dated March 26 through April 5, 2019, Dr. Husain noted that appellant presented with complaints of cervical spine and right shoulder pain, causing pain in her right ear and radiating down her entire right arm, following a work-related injury on March 13, 2019 resulting from “lifting a metal gate.” He reviewed x-rays and MRI scan findings of the cervical spine and right shoulder and noted that appellant had no prior history of injury. Dr. Husain diagnosed cervical radiculopathy, cervical spondylosis with radiculopathy, and incomplete right shoulder rotator cuff tear/rupture. Although he identified the specific employment incident alleged by appellant, he did not provide a pathophysiological explanation as to how lifting a metal gate while at work either caused or contributed to her diagnosed conditions.10 The Board has held that a physician must provide a narrative description of the identified employment incident and a

5
L.C., Docket No. 19-1301 (issued January 29, 2020); J.H., Docket No. 18-1637 (issued January 29, 2020); James E. Chadden, Sr., 40 ECAB 312 (1988). 6 P.A., Docket No. 18-0559 (issued January 29, 2020); K.M., Docket No. 15-1660 (issued September 16, 2016);
Delores C. Ellyett, 41 ECAB 992 (1990).
7
T.H., Docket No. 19-0599 (issued January 28, 2020); K.L., Docket No. 18-1029 (issued January 9, 2019); John J. Carlone, 41 ECAB 354 (1989). 8 S.S., Docket No. 19-0688 (issued January 24, 2020); A.M., Docket No. 18-1748 (issued April 24, 2019); Robert G. Morris, 48 ECAB 238 (1996). 9 T.L., Docket No. 18-0778 (issued January 22, 2020); Y.S., Docket No. 18-0366 (issued January 22, 2020);
Victor J. Woodhams, 41 ECAB 345, 352 (1989).
10
L.T., Docket No. 19-1100 (issued November 13, 2019); M.V., Docket No. 18-0884 (issued December 28, 2018).

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reasoned opinion on whether the employment incident described caused or contributed to appellant’s diagnosed medical condition.11 Further, such generalized statements do not establish causal relationship because they merely repeat appellant’s allegations and are unsupported by adequate medical rationale.12 As such, these reports are insufficient to establish appellant’s claim.

In a series of work status reports dated March 26 through April 5, 2019, Dr. Husain provided diagnoses and noted that appellant could not return to work, but did not opine as to the cause of her diagnosed conditions. The Board has held that medical evidence that does not offer an opinion regarding the cause of an employee’s condition is of no probative value on the issue of causal relationship.13 These reports are, therefore, insufficient to establish appellant’s claim.

Appellant also submitted a March 14, 2019 medical report and a March 26, 2019 Form CA-17 from an unidentifiable healthcare provider. The Board has held that reports that bear illegible signatures cannot be considered probative medical evidence because they lack proper identification that the author is a physician.14 These report, thus, are also insufficient to establish appellant’s claim.15

Finally, the record also contain MRI scan reports of the cervical spine and right shoulder.
The Board has held that diagnostic studies, standing alone, lack probative value on the issue of causal relationship as they do not provide an opinion as to whether there is a relationship between the accepted employment factors and the claimant’s diagnosed conditions.16

As none of the medical evidence appellant submitted constitutes rationalized medical evidence sufficient to establish causal relationship between the accepted March 13, 2019 employment incident and her diagnosed conditions, the Board finds that appellant has not met her burden of proof.17

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.

11
See T.K., Docket No. 18-1239 (issued May 29, 2019).
12
T.W., Docket No. 18-1436 (issued April 10, 2019); see U.B., Docket No. 18-0691 (issued March 12, 2020); J.B., Docket No. 18-1006 (issued May 3, 2019).
13
L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., No. 17-1549 (issued July 6, 2018) 14
J.P., Docket No. 19-0197 (issued June 21, 2019).
15
See M.M., Docket No. 20-0019 (issued May 6, 2020); L.B., supra note 13.
16
See I.C., Docket No. 19-0804 (issued August 23, 2019).
17
R.G., Docket No. 18-0792 (issued March 11, 2020).

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CONCLUSION

The Board finds that appellant has not met her burden of proof to establish a medical condition causally related to the accepted March 13, 2019 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the May 15, 2019 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: September 29, 2020
Washington, DC

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

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

Patricia H. Fitzgerald, Alternate Judge
Employees’ Compensation Appeals Board

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