D.A. and U.S. Postal Service, Post Office, Boston, MA (Board decision, April 17, 2023)

ECAB final decision. The Board set aside OWCP’s denial of D.A.’s injury claim. Medical reports established diagnosed back conditions, and OWCP must decide whether the accepted workplace incident caused them. A party may petition the Board for reconsideration within 30 days of issuance unless the order specifies another period, under 20 C.F.R. § 501.7(a).

Plain-English summary

D.A. reported lower back pain after a January 2020 incident at the post office. Her physician diagnosed several lumbar and sacroiliac conditions. The Board found that this met the diagnosis requirement, but the record still needed a decision on the link between those conditions and the accepted incident.

Decision snapshot

• Authority: 5 U.S.C. § 8101.
• Outcome: Denial set aside; medical causation remanded.
• Key point: A supported diagnosis left the causation question for OWCP.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
D.A., Appellant
)
)
and ) Docket No. 21-1002
) Issued: April 17, 2023
U.S. POSTAL SERVICE, POST OFFICE,
)
Boston, MA, 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
PATRICIA H. FITZGERALD, Deputy Chief Judge JANICE B. ASKIN, Judge

JURISDICTION

On June 21, 2021 appellant filed a timely appeal from a June 3, 2021 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 has met her burden of proof to establish a diagnosed medical condition in connection with the accepted January 24, 2020 employment incident.

FACTUAL HISTORY

On February 5, 2020 appellant, then a 48-year-old mail handler, filed a traumatic injury claim (Form CA-1) alleging that on January 24, 2020 she injured her lower back while in the performance of duty. She explained that she experienced a sharp pain in her lower back as well

1
5 U.S.C. § 8101 et seq. as numbness in her legs with spasms when lifting a heavy mail bin. Appellant stopped work on the date of injury.

In a January 24, 2020 statement, appellant noted that she had recently been working with a large volume of mail. She related that, earlier that day, while at work, she was picking up a heavy bin when she experienced a pull in her lower back, as well as a sharp pain with spasms and numbness in her legs. Appellant noted that she continued to work until she later notified her supervisor after 5:00 p.m. that she was experiencing back pain. She indicated that she was eventually transported to a hospital.

In a January 24, 2020 report, Christina C. Cheng, a physician assistant, noted that appellant presented with acute back pain after lifting a heavy postal bin full of mail at work. Appellant asserted that she had no prior back injury or surgery. Ms. Cheng diagnosed acute bilateral back pain.

In a January 24, 2020 report, Kelley J. Burke, a registered nurse, related that appellant was bending over to pick up something when she experienced a tight pull and numbness.

In a January 24, 2020 emergency room report, Dr. Paul D. Biddinger, Board-certified in emergency medicine, noted that appellant presented with back pain. He observed that she experienced severe low back pain that radiated down into her legs, as well as a tingling sensation in her legs. Dr. Biddinger conducted a physical examination and diagnosed acute bilateral back pain. An after-visit summary of even date reiterated his diagnosis of acute bilateral back pain.

In a February 10, 2020 medical report, Dr. Bonnie A. Southworth, Board-certified in internal medicine, reported that appellant experienced persistent lower back pain and muscle spasms. She observed that appellant had pain and stiffness when lying down. Dr. Southworth conducted a physical examination and diagnosed back pain.

In an undated attending physician’s report (Form CA-20), Dr. Southworth, described appellant’s injury as occurring as a result of lifting a large, heavy postal bin full of mail on January 24, 2020 when she experienced acute lower back pain and spasms. She diagnosed acute lower back pain. In a Form CA-20 dated February 13, 2020, Dr. Southworth reiterated her findings and diagnosis.

A February 28, 2020 magnetic resonance imaging (MRI) scan of the lumbar spine revealed bilateral neural foraminal narrowing as well as narrowing of the bilateral lateral recesses with involvement of the transiting L5 nerve roots and mild spinal canal narrowing at the L4-5 level. It also demonstrated a progression of mild right neural foraminal narrowing as well as mild left neural foraminal narrowing at the L3-4 level.

Appellant underwent physical therapy treatment on March 9, 2020.

In a March 26, 2020 development letter, OWCP informed appellant of the deficiencies of her claim. It advised her of the type of medical evidence necessary to establish her claim and afforded her 30 days to provide the necessary evidence.

2
 In an April 22, 2020 note, Dr. Southworth noted that appellant had persistent back pain and could not sit or stand for any length of time or lift any heavy objects.

By decision dated April 30, 2020, OWCP accepted that the January 24, 2020 employment incident occurred, as alleged, but denied appellant’s claim, finding that she had not submitted medical evidence containing a medical diagnosis in connection with her accepted employment incident. It concluded, therefore, that the requirements had not been met to establish an injury as defined under FECA.

In a January 27, 2020 duty status report (Form CA-17), Dr. Southworth diagnosed lower back pain.

In an April 8, 2020 form report, Dr. Southworth diagnosed persistent low back pain.

In a May 11, 2020 medical report, Dr. Zacharia Isaac, Board-certified in physical medicine and rehabilitation, noted that appellant’s pain started on January 24, 2020 during a work-related incident. He related that she experienced severe flare of pain in her low back with associated buttock numbness that radiated down to the sacral region. Dr. Isaac indicated that appellant was treated in the emergency room and was no longer working. He also indicated that she subsequently underwent physical therapy treatments. Dr. Isaac conducted a physical examination and reviewed the February 28, 2020 MRI scan of the lumbar spine. He diagnosed spondylosis of lumbar region without myelopathy or radiculopathy and exacerbation of low back pain with associated degenerative changes of the disc at the L4-5 level and facet arthropathy at the L4-5 and L5-S1 levels. Dr. Isaac opined that appellant’s low back pain was exacerbated after the accepted January 24, 2020 employment incident. He explained that compounding issues included deconditioning of her core muscles, overweight, and physically demanding job. Dr. Isaac recommended that appellant remain off work.

A July 15, 2020 x-ray of the lumbar spine revealed mild degenerative changes of the cervical spine and transitional lumbar anatomy without evidence of instability on flexion and extension views.

Appellant underwent physical therapy treatments from September 16 through October 21, 2020.

On November 24, 2020 appellant requested reconsideration.

By decision dated March 2, 2020, OWCP denied modification of the April 30, 2020 decision.

In an August 26, 2020 progress report, Dr. Isaac reiterated his findings and diagnoses.

In a December 14, 2020 progress report. Dr. Isaac noted that appellant’s symptoms worsened with movement or sitting, and at nighttime. He indicated that her symptoms decreased with heat or side laying. Dr. Isaac conducted a physical examination and diagnosed sacroiliitis and exacerbation of low back pain with associated degenerative changes of the disc at the L4-5 level and facet arthropathy at the L4-5 and L5-S1 levels. He again opined that appellant’s low back pain was exacerbated after her accepted January 24, 2020 employment incident and explained

3 that compounding issues included deconditioning of her core muscles, overweight, and physically demanding job.

In a February 24, 2021 progress report, Dr. Isaac reiterated his findings and diagnosed exacerbation of low back pain with associated degenerative changes of the disc at the L4-5 level and facet arthropathy at the L4-5 and L5-S1 levels versus S1 joint dysfunction. He again opined that appellant’s low back pain was exacerbated after her accepted January 24, 2020 employment incident and again explained that compounding issues included her physically demanding job.

On April 7, 2021 appellant requested reconsideration.

By decision dated June 3, 2021, OWCP denied modification of the March 2, 2021 decision.

LEGAL PRECEDENT

An employee seeking benefits under FECA2 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,3 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 employment injury.4 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.5

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.6

The medical evidence required to establish a causal relationship between a claimed specific condition and an employment incident is rationalized medical opinion evidence.7 The opinion of the physician must be based on a complete factual and medical background of the employee, must

2
Id.
3
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).
4
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). 5 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).
6
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). 7 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).

4 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.8

ANALYSIS

The Board finds that this case is not in posture for decision. In medical reports dated May 11, August 26, and December 14, 2020, and February 24, 2021, Dr. Isaac recounted the events of the January 24, 2020 work-related incident. He related that appellant experienced severe flare of pain in her low back with associated buttock numbness that radiated down to the sacral region. Dr. Isaac conducted a physical examination, reviewed her diagnostic studies, and diagnosed spondylosis of lumbar region without myelopathy or radiculopathy, sacroiliitis, and exacerbation of low back pain with associated degenerative changes of the disc at the L4-5 level and facet arthropathy at the L4-5 and L5-S1 levels. Therefore, the Board finds that the evidence of record establishes diagnosed medical conditions.

As the medical evidence of record establishes diagnosed medical conditions, the case must be remanded for consideration of the medical evidence with regard to the issue of causal relationship. Following this and other such further development as deemed necessary, OWCP shall issue a de novo decision.

CONCLUSION

The Board finds that appellant has met her burden of proof to establish diagnosed medical conditions. The Board further finds, however, that this case is not in posture for decision as to whether her diagnosed medical condition is causally related to the accepted January 24, 2020 employment incident.

8
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).

5
 ORDER

IT IS HEREBY ORDERED THAT the June 3, 2021 decision of the Office of Workers’ Compensation Programs is set aside and the case is remanded for further proceedings consistent with this decision of the Board.

Issued: April 17, 2023
Washington, DC

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

Patricia H. Fitzgerald, Deputy Chief Judge Employees’ Compensation Appeals Board

Janice B. Askin, Judge
Employees’ Compensation Appeals Board

6