ALVIN L. BARBKNECHT, Employee/Appellant, v. AMERIC DISC, INC., OF MINN. and ARGONAUT-MIDWEST INS. CO., Employer-Insurer, and REGIONS HOSP. and FAIRVIEW HEALTH SERVS., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
MARCH 3, 2005
MEDICAL TREATMENT & EXPENSE - REASONABLE & NECESSARY. Substantial evidence, including the opinion of the independent medical examiner, supports the compensation judge=s determination that the proposed radio frequency neurotomy was not reasonable or necessary to cure or relieve from the effects of the employee=s work-related injury.
CAUSATION - MEDICAL TREATMENT; PRACTICE & PROCEDURE - ADEQUACY OF FINDINGS. The compensation judge=s finding of no causal relationship between the proposed medical procedure and the employee=s work injury is vacated where the single finding is conclusory, the basis of or underlying facts essential to the ultimate decision are not apparent, and differing interpretations could be drawn regarding the effect and/or meaning of the finding.
Affirmed in part and vacated in part.
Determined by: Johnson, C.J., Wilson, J., and Rykken, J.
Compensation Judge: Janice M. Culnane
Attorneys: Gary L. Manka, Katz, Manka, Teplinsky, Due & Sobol, Minneapolis, MN, for the Appellant. M. Shannon Peterson, McCollum, Crowley, Moschet & Miller, Minneapolis, MN, for the Respondents.
THOMAS L. JOHNSON, Judge
The employee appeals the compensation judge=s finding that he failed to prove, by a preponderance of the evidence, that a proposed radio frequency neurotomy treatment is reasonable, necessary and causally related to the employee=s work-related injury. We affirm the finding that the proposed medical treatment is not reasonable or necessary, but vacate the finding that the proposed treatment is not causally related to the employee=s work injury.
Alvin L. Barbknecht, the employee, sustained a severe injury on May 3, 2001, when he fell approximately 15 feet landing on concrete. The employee suffered a closed-head injury with an acute subdural hematoma, a temporal brain contusion, occipital bone fracture, multiple rib fractures and a left clavicular fracture. As a result of the employee=s traumatic brain injury, he sustained left upper extremity weakness and cognitive impairment. The parties agree the employee sustained at least a 48.20 percent permanent partial disability of the whole body and has been permanently and totally disabled since August 25, 2001.
Following his fall, the employee was hospitalized at Regions Hospital until July 2, 2001, when he was transferred to a transitional care unit at Southview Acres. The employee remained a patient at Southview until December 17, 2001, when he was released to return home under the care of Dr. Karl Parens, his family physician. Based upon the employee=s history of a closed-head injury and complaints of headache and fatigue, Dr. Parens ordered a CT scan of the head. The February 2003 CT scan demonstrated no acute findings.
Dr. Parens referred the employee to Dr. Jack Hubbard, a neurologist, for evaluation of his headaches. The employee saw Dr. Hubbard on March 12, 2003, complaining of headaches off and on but worsening over the past few months. The doctor reviewed the February 2003 CT scan which he believed demonstrated some residual encephalomalacia over the right frontal lobe without acute changes. On examination, the doctor noted prominent myofascial trigger points over the neck and shoulders. Dr. Hubbard diagnosed significant head trauma with resulting memory difficulties and left hemiparesis with headaches. The doctor suspected the headaches were secondary to the persistent myofascial trigger points and prescribed a course of physical therapy. In May 2003, Dr. Hubbard noted the employee=s neck pain had significantly improved but the headaches had not improved. In September 2003, the doctor stated that given the employee=s response to cervical epidural steroid injections, it was clear the employee=s neck was the source of his headaches. Dr. Hubbard felt, however, he was running out of treatment options for controlling the headaches.
Dr. Lon Lutz saw the employee in June 2003 for intractable suboccipital neck pain and headaches. The employee denied any prior history of headaches. The doctor opined the employee=s injury likely impacted his cervical spine causing facet joint problems. The doctor instituted a series of trigger point injections. In August 2003, Dr. Lutz noted the employee had some initial improvement but his progress had plateaued. An MRI scan demonstrated multi-level cervical degenerative disc disease with stenosis. The doctor then provided epidural and facet injections which he stated did not provide any long-lasting relief. However, based on the employee=s account that he had some relief following the series of facet injections, Dr. Lutz recommended a radio frequency neurotomy.
Dr. Lutz stated the employee=s history was negative for any complaints of headache prior to the injury and the mechanism of the injury was one that could cause the symptoms complained of by the employee. The doctor stated that with properly selected patients, 70 to 80 percent of those who have significant relief with facet injections will have similar relief with the radio frequency neurotomy for between 18 to 24 months. The doctor stated that if a person got 50 to 60 percent better from facet blocks, that person could reasonably expect to get 50 to 60 percent better from the radio frequency procedure, but for a longer period of time. Based upon the employee=s reports of his level of pain relief from the facet injections, Dr. Lutz concluded the employee would benefit from a radio frequency neurotomy. Dr. Lutz opined the need for the radio frequency neurotomy was caused by the employee=s personal injury.
Dr. Bruce Van Dyne, a neurologist, examined the employee on January 8, 2004, at the request of the employer and insurer. The doctor diagnosed a right frontal temporal brain contusion, occipital bone fracture, multiple rib fractures and a left clavicular fracture. As a result of the traumatic brain injury, Dr. Van Dyne stated the employee had a mild left upper extremity weakness, mild cognitive impairment and apparent mild gait instability. The employee reported chronic headaches and posterior neck pain that developed over the past year, which the doctor opined were secondary to tension or muscle contraction headaches. The doctor opined the employee=s neck symptoms were most likely due to underlying degenerative cervical spondylosis and concluded that both the headaches and neck symptoms were unrelated to the work injury. Based upon his review of Dr. Lutz=s records, Dr. Van Dyne concluded the employee reported only a 30 to 50 percent improvement with the cervical epidural steroid injections. Dr. Van Dyne opined further injections would not be reasonable.
The employee filed a medical request seeking approval for the radio frequency neurotomy recommended by Dr. Lutz. In a Findings and Order filed September 17, 2004, the compensation judge found the employee failed to prove the radio frequency neurotomy was reasonable, necessary and causally related to the May 3, 2001, personal injury. The employee appeals.
1. Reasonableness and Necessity
Dr. Lutz opined that based upon the employee=s response to the facet injections, the employee was a good candidate for a radio frequency neurotomy. The employee argues the facet injections administered by Dr. Lutz allowed him to get out of bed, walk the dog and function around the house as supported by the testimony of the employee and his wife. Medical expenses, the appellant argues, may be reimbursable if the treatment relieves the employee=s symptoms even though the treatment may not have a lasting effect. Accordingly, the employee contends, the compensation judge erred in finding the proposed treatment was not reasonable and necessary and requests this court to reverse that finding. We are not persuaded.
On October 8, 2003, the employee reported several days of excellent relief following facet injections on September 17, but the pain returned and the employee rated his symptoms at 8 on a scale of 0-10. Facet injections on October 8, 2003, resulted in 20 to 30 percent improvement 30 minutes post procedure. A right occipital nerve block on November 12, 2003, resulted in 20 to 30 percent improvement in symptoms 30 minutes post-procedure. When the employee returned on December 3, 2003, he again rated his symptoms at 8 although he stated he had some pain-free days following the last procedure. Another occipital nerve block resulted in 50 to 60 percent improvement in symptoms 30 minutes post-procedure but by December 17, 2003, the employee stated his pain had returned to a level of 8. Dr. Lutz then recommended the radio frequency neurotomy, concluding the employee had good responses on the prior two occasions. A complaint of 8 on a 0 to 10 scale, Dr. Lutz conceded, was an expression of significant continuing pain.
The compensation judge concluded the degree of relief documented by Dr. Lutz from the injections did not support the doctor=s conclusion that the injections were effective in relieving the employee=s pain. Dr. Van Dyne stated the records of Dr. Lutz did not reflect a dramatic decrease of either the employee=s headaches or neck symptoms following the various injections. Dr. Van Dyne stated a 20 to 30 percent improvement was very minimal and even a 50 to 60 percent improvement was really not significant. Even assuming a 50 to 60 percent improvement following the injections, Dr. Van Dyne did not believe that level of improvement justified proceeding with the radio frequency procedure. The compensation judge accepted Dr. Van Dyne=s opinions.
There was, in this case, a difference in medical opinion regarding the reasonableness and necessity of the proposed treatment. This court has stated on many occasions that it is the compensation judge=s responsibility, as trier of fact, to resolve conflicts in expert testimony. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). The compensation judge adopted the opinions of Dr. Van Dyne. Since Dr. Van Dyne=s opinions were adequately founded, this court must affirm the compensation judge=s decision.
2. Causal Connection
The compensation judge found the proposed radio frequency neurotomy was not reasonable or necessary, but further found it was not causally related to the employee=s personal injury. Minn. Stat. ' 176.135 requires employers to furnish any medical care which Amay reasonably be required@ to cure and relieve the effects of the injury. The respondents assert that what the judge intended by the causal connection finding was that the employee=s neck pain and headaches were not an effect of the personal injury. The appellant responds that based upon the lack of findings or explanation the compensation judge=s intent is unclear. We agree.
In Mendez-Merino v. Farmstead Foods, slip op. (W.C.C.A. August 7, 2001), this court stated a compensation judge should Astate with clarity and completeness the facts essential to the ultimate decision so that a reviewing court can determine from the record whether these facts support the judge=s decision@ and Ashould not leave to the reviewing court the obligation to seek or spell out the facts supporting the judge=s decision or to choose between conflicting testimony and inferences.@ On the issue of the relationship between the personal injury and the employee=s neck pain and headaches, the compensation judge made only one finding: that the employee failed to prove the radio frequency neurotomy was causally related to the work injury. In the memorandum, the compensation judge provided a detailed explanation of the basis for the decision that the proposed treatment was not reasonable and necessary. The memorandum, however, does not provide any discussion of or reasons for the causal relationship finding. As a consequence, this court is unable to discern the basis or underlying facts upon which the compensation judge=s decision was based. Accordingly, we vacate the compensation judge=s finding that the proposed radio frequency neurotomy was not casually related to the employee=s personal injury.
 Dr. Lutz described the procedure as injecting a needle in the area of the sensory nerve going to a specific joint to cauterize the nerve to make the joint anesthetic.