V.F. and Department of the Army, Civilian Human Resources Agency, Southwestern Division, Civilian Personnel Advisory Center (Board decision, September 5, 2025)

ECAB final decision. The Board affirmed OWCP's April 7, 2025 decisions denying claim expansion and a right wrist injection. A party may petition the Board for reconsideration within 30 days of issuance unless this order 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

An Army human resources specialist asked OWCP to add headaches and incontinence to her accepted injury and authorize a right carpal tunnel injection. The Board found her doctors did not adequately explain how the accepted injury caused the added conditions. It also found no medical support that the injection was necessary for an accepted wrist condition. It affirmed both denials.

Decision snapshot

• Authority: Federal Employees' Compensation Act, 5 U.S.C. § 8101 et seq.; 20 C.F.R. §§ 501.2(c), 501.3.
• Outcome: Headaches and incontinence not added; right wrist injection not authorized.
• Key point: The medical opinions did not establish causation or medical necessity for the requested treatment.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
V.F., Appellant
)
)
and ) Docket No. 25-0548
)
Issued: September 5, 2025
DEPARTMENT OF THE ARMY, CIVILIAN )
HUMAN RESOURCES AGENCY,
)
SOUTHWESTERN DIVISION, CIVILIAN
)
PERSONNEL ADVISORY CENTER,
)
Fort Worth, TX, Employer
)
__________ )

Appearances: Case Submitted on the Record
Alan J. Shapiro, Esq., for the appellant1
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 May 13, 2025 appellant, through counsel, filed a timely appeal from April 7, 2025 2 merit decisions of the Office of Workers’ Compensation Programs (OWCP). Pursuant to the

1
In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for legal or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. § 501.9(e). No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An attorney or representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject to fine or imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a representative, prior to approval by the Board, may be reported to appropriate authorities for investigation. 2 The Board notes that there is a February 12, 2025 merit decision regarding travel reimbursement, which is also within the Board’s jurisdiction. As counsel did not appeal from the February 12, 2025 decision, the Board will not address the February 12, 2025 decision in this appeal. 20 C.F.R. § 501.3; see E.B., Docket No. 24-0775 (issued September 27, 2024); D.K., Docket No. 22-0111 (issued February 8, 2023); E.R., Docket No. 20-1110 (issued December 23, 2020). Federal Employees’ Compensation Act3 (FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over the merits of this case. 4

ISSUES

The issues are: (1) whether appellant has met her burden of proof to establish expansion of the claim to include headaches and incontinence as causally related to, or a consequence of, the accepted July 18, 2017 employment injury; and (2) whether OWCP properly denied authorization for a therapeutic carpal tunnel injection of the right wrist.

FACTUAL HISTORY

On July 26, 2017 appellant, then a 50-year-old human resources specialist, filed a traumatic injury claim (Form CA-1) alleging that on July 18, 2017 she injured her lower back, neck, shoulders, and wrist when she slipped on a puddle of water and fell onto the floor of the ladies restroom while in the performance of duty. She stopped work on August 9, 2017. OWCP accepted the claim for contusion of the lower back and pelvis, contusion of the right wrist, lumbar disc displacement, and lumbar region spinal stenosis. It paid appellant wage-loss compensation.

On October 12, 2017 appellant underwent an unauthorized arthroscopic debridement of triangular fibrocartilage complex tear, right wrist, and right carpal tunnel release.

On October 25, 2017 appellant sought emergency treatment for onset of incontinence. In a treatment note of even date, Dr. Andrew Indresano, a Board-certified orthopedic surgeon, related that she experienced a slip and fall at work and was experiencing worsening upper and lower extremity symptoms including numbness in her left upper extremity and on the left side of her body. Appellant also reported and exhibited intermittent bouts of urinary incontinence. Dr. Indresano noted a worsening neurologic examination including perianal absent sensation and decreased rectal tone. He determined that with appellant’s known severe stenosis and myelopathy and her instance of urinary incontinence in his office she required emergency surgery. On October 25, 2017 appellant underwent an unauthorized C5-7 anterior cervical discectomy and fusion.

In a November 13, 2017 note, Dr. Rory L. Allen, an osteopath, related that appellant had undergone emergency cervical surgery secondary to urinary incontinence, progressive motor weakness, and intractable pain. Appellant continued to experience significant weakness in the left upper extremity and left lower extremity with footdrop and urinary incontinence following the surgery.

3
5 U.S.C. § 8101 et seq.
4
The Board notes that following the April 7, 2025 decision, OWCP received additional evidence. 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.

2
Dr. Mark Valente, an osteopath and Board-certified orthopedic surgeon, completed an April 3, 2018 report and related that appellant continued to experience incontinence, falls, and difficulty with memory. He related that it was possible that her injury may have caused chronic or irreversible spinal cord damage causing her persistent arm and leg pain, paresthesia, and incontinence.

On May 4, June 8, and July 9, 2018 Dr. Hamid H. Kadiwala, a Board-certified clinical neurophysiologist, related that appellant fell in the bathroom at work in July 2018 hitting the back of her head and right wrist, sustaining headaches, but no loss of consciousness. Appellant continued to report numbness in the hands and face, dropping objects, difficulty with executive function and attention. She also experienced syncope and fell due to difficulty feeling the floor. Appellant continued to experience incontinence and daily headaches with associated nausea, photophobia, and phonophobia. Dr. Kadiwala diagnosed loss of consciousness, headaches, neuropathy, lumbar radiculopathy, incontinence, memory deficit, cervical spondylosis, and weakness. He attributed her headaches to impact from the employment injury. Dr. Kadiwala found that the etiology of her weakness and numbness was unclear but determined that it was likely related to the injuries sustained during her employment injury. He further determined that as a result of her injuries and resulting diagnostic studies, she underwent right wrist surgery and cervical spine surgery in October 2017.

In reports dated June 15, through December 5, 2018, Dr. Allen related that appellant reported aching and throbbing cervical pain with associated spasms and headaches. He reported headaches, urinary incontinence, and depression. Dr. Allen found that appellant was totally disabled due to severe pain, limited range of motion, pain medications, limited mobility, muscle spasms, upper and lower extremity neuropathic complaints of numbness and tingling, and difficulty with prolonged standing, walking, and weightbearing through August 2018 and then released her to perform light-duty work effective September 25, 2018. He also noted that appellant reported a head injury.

Dr. Kadiwala completed a December 4, 2018 report and reviewed appellant’s electrodiagnostic studies, finding them unremarkable. He diagnosed weakness and numbness, finding that the etiology was unclear, but “likely related to the injuries sustained during her accident.” Dr. Kadiwala noted that her symptoms had worsened following surgery. He also diagnosed neuropathy and headaches. Dr. Kadiwala opined that based on history and examination appellant experienced chronic headaches due to impact from the accepted July 18, 2017 employment injury.

On December 19, 2018 OWCP expanded its acceptance of appellant’s claim to include cervical radiculopathy, cervical spinal stenosis, and cervical spondylosis with myelopathy.

On March 19, 2019 Dr. Indresano performed an OWCP-authorized L5-S1 and L5-S1 anterior lumbar interbody fusions. He examined appellant on April 8, 2019 and recommended an additional L5-S1 laminectomy with bilateral facetectomy to treat her persistent and significant pain in the hips and lateral thighs bilaterally. On April 16, 2019 Dr. Indresano performed an emergency lumbar bilateral L5 laminectomy and lumbar bilateral L5-S1 facetectomy with foraminotomy. On July 10 and 31, 2019 he noted appellant’s improved back pain with increased neck pain radiating down both arms with difficulty with rapid opening and closing of her hands

3 bilaterally and other fine motor movement issues. Dr. Indresano diagnosed cervicalgia and recommended additional cervical testing.

In reports dated September 4 and December 4, 2019, Dr. Indresano reviewed electrodiagnostic studies and diagnosed bilateral ulnar motor neuropathy and bilateral median motor neuropathy with no radiculopathy. He related that appellant experienced neck pain that radiated to her arms bilaterally and occasional urinary incontinence. Dr. Indresano diagnosed bilateral carpal tunnel syndrome.

On May 26, July 6, and November 20, 2020 Dr. Neerav Bhatla, a Board-certified anesthesiology specializing in the pain medicine, examined appellant due to chronic back pain with bilateral lower extremity radiation and neck pain radiating to her bilateral upper extremities and increased frequency headaches. He noted that appellant was concerned that her frequent headaches would transform into migraines. Dr. Bhatla diagnosed chronic pain, lumbar radiculopathy. Appellant also provided treatment notes from Krista Qualls and Erin Herrmann, nurse practitioners, in Dr. Bhatla’s practice.

On July 1, 2020 appellant underwent a magnetic resonance (MRI) scan of her brain, which demonstrated mild white matter foci most likely secondary to migrain es and/or chronic microvascular ischemia.

On October 5, 2020 appellant underwent a right wrist MRI scan which demonstrated suspected triangular fibrocartilage complex tear, tricompartmental wrist effusions, tendon strain, mild tenosynovitis and widening of the scapholunate interspace possibly due to a ligament tear. An MRI scan of the right hand of even date demonstrated mild tenosynovitis of the digit flexor tendons and mild osteoarthritis.

On November 23, 2020 appellant underwent electromyogram and nerve conduction velocity (EMG/NCV) testing which demonstrated left-sided carpal tunnel syndrome, bilateral ulnar motor neuropathy across the elbows, left-sided ulnar sensory neuropathy, right-sided median motor neuropathy at the elbow, left-sided C4 radiculitis, right-sided C5 radiculitis, and left-sided C6 radiculitis.

In a January 20, 2021 letter, Dr. Allen opined that appellant sustained a right wrist condition when she slipped and fell while in the performance of duty on July 18, 2017. He explained that her right wrist and hand sustained compression, torsional, and rotational forces directly stretching the soft tissues, ligaments, tendons, and nerves beyond normal physiological limits and directly causing a right median nerve lesion and carpal tunnel syndrome . Dr. Allen requested that OWCP expand the acceptance of appellant’s claim to include these additional conditions.

In a February 1, 2021 development letter, OWCP informed appellant that the evidence submitted was insufficient to warrant expansion of the acceptance of her claim to include additional conditions. It advised her of the type of factual and medical evidence needed and afforded her 30 days to submit the necessary evidence.

In a February 1, 2021 note, Dr. Allen reviewed the electrodiagnostic studies and provided his findings on physical examination. He diagnosed intervertebral disc displacement, cervical

4 spondylosis with myelopathy, lumbar spinal stenosis, lumbar radiculopathy, contusion of the right wrist, contusion of the lower back and pelvis, mechanical complication of other ocular prosthetic devices, implants, and grafts, cervical radiculopathy and cervical spinal stenosis. Dr. Allen noted that the additional conditions of right median nerve lesion, right wrist pain, and right carpal tunnel syndrome were pending approval. He related that appellant reported a head injury and continued to experience urinary incontinence.

By decision dated March 2, 2021, OWCP declined to expand the acceptance of appellant’s claim to include right median nerve lesion and right carpal tunnel syndrome.

On March 8, 2021 appellant, through counsel, requested an oral hearing before a representative of OWCP’s Branch of Hearings and Review. A hearing was held on May 25, 2021.

On June 10, 2021 Dr. Allen again requested that appellant’s claim be expanded to include additional right wrist and hand conditions including right median nerve lesion, right wrist pain, right wrist sprain, and right carpal tunnel syndrome. He related that when she fell on July 18, 2017 her right arm was outstretched and she sustained direct impact trauma to her right wrist and hand, resulting in compression and torsional forces.

By decision dated August 5, 2021, OWCP’s hearing representative affirmed the March 2, 2021 decision.

On September 13, 2021 appellant, through counsel, requested reconsideration.

By decision dated December 10, 2021, OWCP vacated the August 5, 2021 decision in part, finding that the medical evidence of record was sufficient to establish a right wrist sprain as causally related to the accepted employment injury. However, OWCP denied modification of the August 5, 2021 decision in part, finding that the medical evidence of record was insufficient to establish a right median nerve lesion and right carpal tunnel syndrome as causally related to the accepted employment injury.5

As of September 19, 2023, appellant sought treatment from Addison Marshall, Kurt Lee, and Roy Blount, physician assistants.

On January 11, 2024 appellant underwent a right wrist MRI scan which demonstrated a small effusion of the distal radioulnar joint.

On January 10, 2024 Dr. Russell Jackson, an osteopath and Board-certified hand surgeon, examined appellant due to right hand pain, numbness, and tingling. He related her history of injury and performed a physical examination noting that her Phalen’s test and Tinel’s sign were negative. Dr. Jackson opined that appellant’s symptoms were likely to originate in her neck rather than from carpal tunnel syndrome. He requested authorization of a diagnostic carpal tunnel injection .

In a January 24, 2024 report, Dr. Frank Kuwamura, a Board-certified orthopedic surgeon, related appellant’s history of injury to include a fall on July 18, 2017 at work during which she hit

5
On December 10, 2021 OWCP formally expanded the acceptance of the claim to include right wrist sprain.

5 her head. He recounted her ongoing symptoms of cervical pain and bilateral upper extremity radiculopathy, and low back pain. Dr. Kuwamura reviewed appellant’s electrodiagnostic studies and diagnosed cervicalgia, low back pain, cervical and lumbar radiculopathy, chronic pain, and post-laminectomy syndrome with cervical/lumbar axial radicular pain. He recommended additional spinal surgeries.

On July 26, 2024 appellant underwent an EMG/NCV study which demonstrated bilateral radiculopathies at C5, C6, and right C7 radiculopathy and bilateral carpal tunnel syndrome.

In a September 3, 2024 development letter, OWCP informed appellant of the deficiencies of her request for authorization of therapeutic carpal tunnel injection of the right wrist. It advised her of the type of medical evidence necessary and afforded her 30 days to submit the necessary evidence.

On June 26 and September 4, 2024 Dr. Anton Jorgenson, a Board-certified orthopedic surgeon, noted that appellant had sustained a work-related injury with neck and low back pain. He diagnosed cervical stenosis and related appellant’s symptoms of severe pain into the right trapezius and upper extremity, numbness of all fingers on the right, and a recurrence of bladder incontinence. Dr. Jorgenson proposed a two-level anterior cervical decompression fusion at C3-4 and C4-5.

In an October 10, 2024 report, Dr. Don Michael Thompson, an internist, related appellant’s history of injury on July 18, 2017. He diagnosed lumbar disc displacement, lumbar spinal stenosis, cervical radiculopathy and spinal stenosis, and contusions of the right wrist, lower back, and pelvis. Dr. Thompson noted appellant’s concerns with episodic incontinence. He related that she was awaiting scheduling for a cervical laminectomy.

On October 11, 2024 Dr. Jorgenson diagnosed cervical stenosis and recommended a C3-4 and C4-5 revision cervical arthroplasty.

On November 8, 2024 Dr. Jorgensen provided an addendum report and recounted that appellant was experiencing repeated episodes of urinary incontinence (more than five episodes a day) and fecal incontinence (more than three episodes a day) that limited her ability to work and leave her home. Appellant also reported daily headaches which began in her mid-neck and radiated to the base of her skull, temporal auricular region, and retro orbital region , which he found were consistent with the C4 nerve root. Dr. Jorgenson related that appellant experienced radiating pain into her bilateral trapezius and upper extremities, that she was unable to raise her left arm over her head, balance issues, fine motor skills issues, and poor handwriting. He opined that these symptoms were concerning for worsening myelopathy related to cervical stenosis and again recommended a two-level cervical arthroplasty.

In a November 20, 2024 development letter, OWCP noted that appellant’s physician had provided support for consequential conditions of incontinence and headaches. It informed her that the evidence was insufficient to warrant expansion of the acceptance of her claim to include additional conditions. OWCP advised appellant of the type of factual and medical evidence needed and afforded her 30 days to submit the necessary evidence .

6
By decision dated December 10, 2024, OWCP denied appellant’s request for therapeutic carpal tunnel injection of the right wrist finding that it was not medically necessary to address the effects of her accepted July 18, 2018 employment injury.

OWCP continued to receive evidence. In a November 19, 2024 report, Dr. Thompson noted the July 18, 2017 employment injury and related appellant’s symptoms of worsening bladder control, bilateral radicular pain and constant loss of sensation to the fingertips, decreased grip strength. He diagnosed lumbar disc displacement and spinal stenosis, and cervical radiculopathy and spinal stenosis, and contusions of the right wrist, lower back, and pelvis.

On April 12, 2024 Dr. Jackson determined that the August 20, 2019 EMG/NCV study did not demonstrate carpal tunnel syndrome. In a November 17, 2024 report, he explained that a diagnostic carpal tunnel injection was related to appellant’s July 18, 2017 employment injury as her current symptoms were concerning for possible recurrence of her carpal tunnel syndrome due to scar tissue from the previous surgery. Dr. Jackson requested the injection to help determine the appropriate diagnosis and whether further surgical management was indicated.

In a December 17, 2024 development letter, OWCP informed appellant of the deficiencies of her request for authorization of therapeutic carpal tunnel injection. It advised her of the type of medical evidence necessary and afforded her 30 days to submit the necessary evidence.

OWCP continued to receive evidence. In a November 19, 2024 report, Dr. Tisdall diagnosed chronic pain syndrome and lumbar spondylosis with radiculopathy and recommended an additional epidural steroid injection. Mr. Blount provided additional reports dated November 18 through 19, 2024.

By decision dated December 23, 2024, OWCP denied expansion of the acceptance of appellant’s claim to include incontinence and headaches as causally related to, or a consequence of, her accepted July 18, 2018 employment injury.

On December 24, 2024 appellant, through counsel, requested an oral hearing before a representative of OWCP’s Branch of Hearings and Review regarding the December 10, 2024 denial of authorization for a therapeutic carpal tunnel injection of the right wrist.

On January 2, 2025 appellant, through counsel, requested an oral hearing before a representative of OWCP’s Branch of Hearings and Review regarding the December 23, 2024 denial of expansion to include headaches and incontinence as causally related to , or a consequence of, the accepted employment injury.

OWCP continued to receive evidence. In a December 11, 2024 report, Dr. Jorgensen recounted that appellant was experiencing increasing pain into the right trapezius and right upper extremity consistent with cervical radiculopathy from the C4 and C5 nerve roots . She related numbness in all of her fingers on the right hand and repeated episodes of urinary incontinence (more than five episodes a day) and fecal incontinence (more than three episodes a day) that limited her ability to work and leave her home. Appellant also reported daily headaches which began in her mid-neck and radiated to the base of her skull, temporal auricular region, and retro orbital region, which he found were consistent with the C4 nerve root. Dr. Jorgenson noted that she also experienced balance issues, decreased fine motor skills issues, and poor handwriting. He opined

7 that these symptoms were concerning for worsening myelopathy related to cervical stenosis and again recommended a two-level anterior cervical decompression and fusion.

On January 15, 2025 appellant responded to the November 20, 2024 development letter and asserted that she first began to experience urinary incontinence following the July 18, 2017 employment injury. She further related that when she fell, she sustained a head injury with memory loss, headaches, dizziness, and nausea and requested that her claim be expanded to include this condition. Appellant asserted that her right wrist injury resulted in loss of grip strength. She related that she was experiencing increasing neck pain, that she frequently fell, and that she dropped things.

On January 14, 2025 Dr. Thompson described the July 18, 2017 employment injury and recounted appellant’s symptoms or radiating pain to all extremities including numbness to all fingers and toes. He diagnosed intervertebral disc displacement lumbar region, cervical radiculopathy, and right wrist contusion.

On January 28, 2025 Dr. Jorgensen performed C3-4 and C4-5 revision cervical disc arthroplasty.

In a February 24, 2025 report, Dr. Jorgensen noted that appellant complained of severe right upper extremity weakness and pain following surgery and that a stroke was ruled out. She experienced a drooping mouth with numbness and weakness on the right side of her face and difficulty swallowing. Appellant walked with an antalgic gait.

Appellant’s oral hearing took place on March 5, 2025.

OWCP continued to receive evidence. In notes dated January 30 through February 1, 2025, Dr. Derry Rajan, a Board-certified family practitioner, diagnosed degenerative disease and chronic cervical radiculopathy/myelopathy with worsening right-sided weakness and a traumatic corneal abrasion. Dr. Jorgensen examined appellant on January 30, 2024 and observed inflammation of the right eye and 4/5 weakness of the right deltoid, which he diagnosed as mild postoperative C5 palsy. Appellant underwent physical therapy.

By decision dated April 7, 2025, OWCP’s hearing representative affirmed OWCP’s December 10, 2024 decision denying appellant’s request for therapeutic carpal tunnel injection of the right wrist.

By separate decision dated April 7, 2025, OWCP’s hearing representative affirmed OWCP’s December 23, 2024 decision denying expansion of the acceptance of the claim to include incontinence and headaches as causally related to, or a consequence of, her accepted July 18, 2018 employment injury.

8
LEGAL PRECEDENT -- ISSUE 1

When an employee claims that a condition not accepted or approved by OWCP was due to an employment injury, he or she bears the burden of proof to establish that the condition is causally related to the employment injury. 6

To establish causal relationship between the condition as well as any attendant disability claimed and the employment injury, an employee must submit rationalized medical evidence. 7 The opinion of the physician must be based on a complete factual and medical background of the claimant, 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 claimant. 8 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. 9

In discussing the range of compensable consequences, once the primary injury is causally connected with the employment, the question is whether compensability should be extended to a subsequent injury or aggravation related in some way to the primary injury. The basic rule is that a subsequent injury, whether an aggravation of the original injury or a new and distinct injury, is compensable if it is the direct and natural result of a compensable primary injury. 10

ANALYSIS -- ISSUE 1

The Board finds that appellant has not met her burden of proof to establish expansion of the claim to include headaches and incontinence as causally related to, or a consequence of, the accepted July 18, 2017 employment injury.

Beginning on November 8, 2024, Dr. Jorgensen reported ongoing incontinence. He attributed these conditions to worsening myelopathy related to cervical stenosis. However, Dr. Jorgensen provided only a conclusory opinion on causal relationship. He did not provide medical rationale explaining, physiologically, how appellant’s additional diagnosed conditions were caused or aggravated by the accepted July 18, 2017 employment injury. 11 As Dr. Jorgensen 6 D.M., Docket No. 24-0512 (issued December 9, 2024); L.F., Docket No. 20-0359 (issued January 27, 2021); S.H., Docket No. 19-1128 (issued December 2, 2019); M.M., Docket No. 19-0951 (issued October 24, 2019); Jaja K. Asaramo, 55 ECAB 200, 204 (2004). 7 D.M., id.; L.F., id.; T.K., Docket No. 18-1239 (issued May 29, 2019); M.W., 57 ECAB 710 (2006); John D.
Jackson, 55 ECAB 465 (2004).
8
D.T., Docket No. 20-0234 (issued January 8, 2021); D.S., Docket No. 18-0353 (issued February 18, 2020); T.K., id.; I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 9 See D.T., id.; P.M., Docket No. 18-0287 (issued October 11, 2018).
10
F.R., Docket No. 24-0075 (issued March 4, 2024); V.K., Docket No. 19-0422 (issued June 10, 2020); K.S., Docket No. 17-1583 (issued May 10, 2018).
11
S.S., Docket No. 23-0391 (issued October 24, 2023); see F.H., Docket No. 18-1238 (issued January 18, 2019);
J.R., Docket No. 18-0206 (issued October 15, 2018).

9 failed to provide rationale in support of causal relationship between the additional diagnosed conditions and the accepted July 18, 2017 employment injury, this evidence is of limited probative value and is insufficient to establish expansion of the claim.

On April 3, 2018 Dr. Valente related that it was possible that the accepted employment incident may have caused chronic or irreversible spinal cord damage causing urinary incontinence. A medical report is of limited probative value on the issue of causal relationship if it contains an opinion regarding causal relationship which is unsupported by medical rationale. 12 Medical opinions that are speculative or equivocal are of diminished probative value.13 For these reasons, Dr. Valente’s reports are insufficient to establish expansion of the claim.

In reports dated February 2019 through January 20, 2021, Dr. Allen diagnosed urinary incontinence. Dr. Jorgenson diagnosed a recurrence of bladder incontinence in June 2024. On October 10, 2024 Dr. Thompson diagnosed bladder incontinence. These physicians did not, however, provide an opinion on causal relationship. 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. 14 Therefore, this evidence is insufficient to establish an expansion of the claim.

In a series of reports dated May 4 through December 4, 2018, Dr. Kadiwala opined that appellant hit her head on July 18, 2017 and sustained headaches associated with nausea, photophobia, and phonophobia. He attributed her headaches to impact from the employment injury. On November 8 and December 11, 2024 Dr. Jorgensen listed appellant’s symptom of daily headaches which began in her neck and radiated to the base of her skull. He opined that these headaches were consistent with worsening myelopathy in the C4 nerve root. OWCP authorized surgery at the C3, C4, and C5 levels. Drs. Kadiwala and Jorgensen provided only a conclusory opinion on causal relationship. These physicians did not provide medical rationale explaining, physiologically, how appellant’s additional diagnosed conditions were caused or aggravated by the accepted July 18, 2017 employment injury. 15 As Drs. Kadiwala and Jorgensen failed to provide rationale in support of causal relationship between the additional diagnosed conditions and the accepted July 18, 2017 employment injury, this evidence is of limited probative value and is insufficient to establish expansion of the claim.

Dr. Allen, in reports dated June 15 through December 5, 2018, diagnosed cervical pain with associated spasms and headaches. However, the Board has held that pain is a description of

12
J.H., Docket No. 24-0415 (issued May 23, 2024); C.C., Docket No. 15-1056 (issued April 4, 2016); see T.M., id.; Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006); William C. Thomas, 45 ECAB 591 (1994). 13 See L.B., Docket No. 23-0099 (issued July 26, 2023); C.C., Docket No. 22-0609 (issued October 25, 2022); H.A., Docket No. 18-1455 (issued August 23, 2019); Ricky S. Storms, 52 ECAB 349 (2001) (while the opinion of a physician supporting causal relationship need not be one of absolute medical certainty, the opinion must not be speculative or equivocal. The opinion should be expressed in terms of a reasonable degree of medic al certainty). 14 A.S., Docket No. 21-1263 (issued July 24, 2023); A.P., Docket No. 18-1690 (issued December 12, 2019); J.H., Docket No. 19-0383 (issued October 1, 2019).
15
Supra note 13.

10 a symptom, not a diagnosis of a medical condition. 16 Medical reports lacking a firm diagnosis are of no probative value. 17 Therefore, this evidence is insufficient to establish appellant’s claim.

In reports dated May 26 through November 20, 2020, Dr. Bhatla found increased frequency headaches. He did not, however, provide an opinion on causal relationship . 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. 18 Therefore, this evidence is insufficient to establish an expansion of the claim.

Appellant also submitted a series of electrodiagnostic studies, physical therapy reports, and reports from physician assistants. However, certain health care providers such as nurses, physician assistants, and physical therapists are not considered physicians under FECA and, therefore, are not competent to provide a medical opinion. 19 Moreover, the Board has held that diagnostic studies, standing alone, lack probative value on the issue of causal relationship. 20

As the medical evidence of record is insufficient to establish the expansion of the claim to include headaches and incontinence as causally related to, or a consequence of, the accepted July 18, 2017 employment injury, the Board finds that appellant has not met her burden of proof.

LEGAL PRECEDENT -- ISSUE 2

Section 8103(a) of FECA 21 provides that the United States shall furnish to an employee who is injured while in the performance of duty, the services, appliances, and supplies prescribed by or recommended by a qualified physician, which OWCP considers likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of the monthly compensation. 22

16
See K.S., Docket No. 19-1433 (issued April 26, 2021); S.L., Docket No. 19-1536 (issued June 26, 2020); D.Y., Docket No. 20-0112 (issued June 25, 2020).
17
See C.J., Docket No. 25-0072 (issued January 17, 2025); A.C., Docket No. 20-1510 (issued April 23, 2021); J.P., Docket No. 20-0381 (issued July 28, 2020); R.L., Docket No. 20-0284 (issued June 30, 2020); see also L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., Docket No. 17-1549 (issued July 6, 2018). 18 Id.
19
Section 8102(2) of FECA provides as follows: physician includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law. 5 U.S.C. § 8102(2); 20 C.F.R. § 10.5(t). See Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3a(1) (May 2023); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006) (lay individuals such as physician assistants, nurses, and physical therapists are not competent to render a medical opinion under FECA). 20 F.D., Docket No. 19-0932 (issued October 3, 2019); J.S., Docket No. 17-1039 (issued October 6, 2017).
21
5 U.S.C. § 8103(a).
22
Id.; see J.K., Docket No. 20-1313 (issued May 17, 2021); Thomas W. Stevens, 50 ECAB 288 (1999).

11
In interpreting this section of FECA, the Board has recognized that OWCP has broad discretion in determining whether a particular type of treatment is likely to cure or give relief. 23 The only limitation on OWCP’s authority is that of reasonableness. 24

Abuse of discretion is generally shown through proof of manifest error, clearly unreasonable exercise of judgment, or actions taken which are contrary to both logic and probable deductions from established facts. It is not enough to merely show that the evidence could be construed to produce a contrary factual conclusion. 25

While OWCP is obligated to pay for treatment of employment-related conditions, appellant has the burden of proof to establish that the expenditures were incurred for treatment of the effects of an employment-related injury or condition. 26 Proof of causal relationship in a case such as this must include supporting rationalized medical evidence.27 In order for a procedure to be authorized, appellant must establish that the procedure was for a condition causally related to the employment injury and that the procedure was medically warranted. 28 Both of these criteria must be met in order for OWCP to authorize payment. 29

ANALYSIS -- ISSUE 2

The Board finds that OWCP properly denied authorization for a therapeutic carpal tunnel injection of the right wrist.

In reports dated January 10 through November 17, 2024, Dr. Jackson examined appellant due to right hand pain, numbness and tingling. He recounted her history of injury and performed a physical examination noting that her Phalen’s test and Tinel’s sign were negative. Dr. Jackson opined that her symptoms were likely to originate in her neck rather than from carpal tunnel syndrome. He requested authorization of a diagnostic carpal tunnel injection. However, Dr. Jackson determined that the August 20, 2019 EMG/NCV study did not demonstrate carpal tunnel syndrome. He explained that a diagnostic carpal tunnel injection was related to appellant’s July 18, 2017 employment injury as her current symptoms were concerning for possible recurrence of her carpal tunnel syndrome due to scar tissue from the previous surgery. Dr. Jackson requested

23
R.C., Docket No. 18-0612 (issued October 19, 2018); W.T., Docket No. 08-812 (issued April 3, 2009).
24
See S.Y., Docket No. 24-0443 (issued May 28, 2024); see D.C., Docket No. 20-0854 (issued July 19, 2021); C.L., Docket No. 17-0230 (issued April 24, 2018); D.K., 59 ECAB 141 (2007). 25 See E.F., Docket No. 20-1680 (issued November 10, 2021); J.L., Docket No. 18-0503 (issued October 16, 2018);
Daniel J. Perea, 42 ECAB 214, 221 (1990).
26
R.M., Docket No. 19-1319 (issued December 10, 2019); J.T., Docket No. 18-0503 (issued October 16, 2018);
Debra S. King, 44 ECAB 203, 209 (1992); Zane H. Cassell, 32 ECAB 1537, 1540-41 (1981). 27 K.W., Docket No. 18-1523 (issued May 22, 2019); C.L., Docket No. 17-0230 (issued April 24, 2018); M.B., 58 ECAB 588 (2007); Bertha L. Arnold, 38 ECAB 282 (1986). 28 T.A., Docket No 19-1030 (issued November 22, 2019); John E. Benton, 15 ECAB 48, 49 (1963).
29
J.L., Docket No. 18-0990 (issued March 5, 2019); R.C., 58 ECAB 238 (2006); Cathy B. Millin, 51 ECAB 331, 333 (2000).

12 the injection to help determine the appropriate diagnosis and whether further surgical management was indicated. Dr. Jackson did not explain why the recommended surgical procedures were medically necessary for the treatment of the accepted right wrist sprain.30 As the conditions for which the injection was requested were not employment related, the procedures were not medically warranted.31 The reports from Dr. Jackson are, therefore, insufficient to establish that the requested procedure was medically necessary and causally related to the accepted employment injury.

Appellant also submitted electrodiagnostic studies. The Board has held that diagnostic studies, standing alone, lack probative value on the issue of causal relationship. 32

As there is no medical evidence of record establishing that appellant’s requested procedure was medically necessary or causally related to the accepted employment injury, the Board finds that OWCP did not abuse its discretion in denying appellant’s request to authorize therapeutic carpal tunnel injection of the right wrist.

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 has not met her burden of proof to establish expansion of the claim to include headaches and incontinence as causally related to, or a consequence of, the accepted July 18, 2017 employment injury. The Board further finds that OWCP properly denied authorization for a therapeutic carpal tunnel injection of the right wrist.

30
See S.T., Docket No. 24-0571 (issued June 14, 2024); C.L., Docket No. 24-0249 (issued April 15, 2024); K.W., Docket No. 18-1523 (issued May 22, 2019); C.L., Docket No. 17-0230 (issued April 24, 2018); M.B., 58 ECAB 588 (2007); Bertha L. Arnold, 38 ECAB 282 (1986). 31 J.B., Docket No. 21-0854 (issued May 18, 2023); see D.S., Docket No. 19-1698 (issued June 18, 2020).
32
Supra note 26.

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ORDER

IT IS HEREBY ORDERED THAT the April 7, 2025 decisions of the Office of Workers’ Compensation Programs are affirmed.

Issued: September 5, 2025
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

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