NANCY L. LARSEN, Employee/Appellant, v. KRAFT FOODS, INC., SELF-INSURED/BROADSPIRE, INC., Employer.
WORKERS= COMPENSATION COURT OF APPEALS
AUGUST 29, 2007
MEDICAL TREATMENT & EXPENSE - TREATMENT PARAMETERS; RULES CONSTRUED - MINN. R. 5221.6200, SUBP. 3B(2). Where the medical records reflected that the employee=s subjective complaints remained at a high level, that her pain continued, that her function had not increased significantly, and that her objective findings were unchanged in the medical records, the compensation judge=s conclusion that the employee=s physical therapy was not sufficiently effective in Amaintaining functional status@ to entitle the employee to treatment beyond an additional twelve visits under Minn. R. 5221.6200, subp. 3B(2), was not clearly erroneous and unsupported by substantial evidence.
MEDICAL TREATMENT & EXPENSE - REASONABLE & NECESSARY. Substantial evidence, including expert medical opinion, supports the compensation judge=s denial of approval for payment of expenses related to additional physical therapy.
PERMANENT PARTIAL DISABILITY - SUBSTANTIAL EVIDENCE. Where the employee=s condition did not qualify for a permanency rating under the permanency rules, the compensation judge did not err in accepting expert medical opinion to that effect, and the compensation judge=s denial of the claim for permanent partial disability benefits is affirmed.
Determined by: Rykken, J., Wilson, J., and Stofferahn, J.
Compensation Judge: Carol A. Eckersen
Attorneys: Nancy L. Larsen, pro se Appellant. David J. Klaiman, Aafedt, Forde, Gray, Monson & Hager, Minneapolis, MN, for the Respondent.
MIRIAM P. RYKKEN, Judge
The employee appeals from the compensation judge=s denial of the employee=s claims for permanent partial disability benefits and expenses related to additional physical therapy. We affirm.
On October 3, 2002, Ms. Nancy L. Larsen, the employee, sustained an admitted work-related injury while employed by Kraft Foods, Inc. On that date, Kraft Foods, the employer, was self-insured for workers= compensation liability, with claims administered by Broadspire. At the time of her injury, the employee reached over her head to pull a 65- to 80-pound empty pallet down from a stack of pallets. As a pallet started to fall, she caught it at chest level and moved it to the floor, noting immediate pain in her neck and upper back. As a result of this incident, the employee sustained a soft-tissue strain or sprain injury to her trapezius muscle and neck, and thoracic outlet syndrome.
The employee sought medical treatment that same day with Dr. David Miller at the New Ulm Medical Center. Dr. Miller obtained x-rays and diagnosed a left trapezius strain. At that point, he released the employee to return to work with a restriction of no lifting over five pounds and no overhead reaching; he also prescribed Naprosyn and Flexeril. The employee received follow-up medical treatment with Dr. Miller, who later referred her for an orthopedic consultation with Dr. Colah. At the time of Dr. Colah=s initial examination on January 22, 2003, the employee continued to work with the employer, with a restriction of no lifting over 25 pounds and a limitation of her overhead activities.
On January 22, 2003, the employee underwent an independent medical examination with Dr. Thomas Raih, at the request of the employer. He concluded that the employee=s symptoms resulted from her October 3, 2002, injury, and diagnosed a resolving right neck and shoulder strain. He recommended six additional physical therapy visits on a tapering basis during the month following the examination, with treatments focusing specifically on active strengthening of the right shoulder musculature. Dr. Raih concluded that the employee had not yet reached maximum medical improvement (MMI) from her work injury. He also concluded that, based upon her improvement, she would reach MMI as of March 1, 2003, and anticipated that she would have no permanent partial disability rating. Dr. Raih also commented that by March 1, 2003, the employee should be able to return to her regular work duties without restrictions, and that until then she could work full time within restrictions of no lifting over 25 pounds and only occasional overhead activity.
Dr. Colah reexamined the employee on January 30, 2003, at which time she reported symptoms in her neck and right shoulder. She also reported that she had experienced pain at night, and noticed pain when lifting her right upper extremity. At some point in early 2003, the employee consulted Dr. Todd Gunnar Holmes in St. Louis Park. Dr. Holmes diagnosed a dislocation of the second rib and evidently manually reduced the dislocation. He also recommended physical therapy.
On May 7, 2003, the employee consulted Dr. Mario DeSouza, orthopedic surgeon. He conducted an examination and referred the employee for x-rays of her right shoulder and right clavicle. Dr. DeSouza=s examination showed full motion of the shoulder and neck and some swelling over the right trapezius area at its insertion into the scapula. He also found tenderness over the right clavicle and some limited motion of the shoulder with limited abduction. The x-rays of the right clavicle showed some cystic changes in the distal clavicle that appeared to be chronic but no fracture or dislocation. The x-ray report noted some acromioclavicular joint widening suggesting Grade I acromioclavicular separation. Dr. DeSouza evidently commented that he was not familiar with techniques of treatment being used by Dr. Holmes, and that he was unfamiliar with the manual reduction of rib dislocations reportedly performed on the employee=s rib by Dr. Holmes.
The employee also underwent an EMG for her right upper extremity on June 11, 2003; the findings were within normal parameters. During additional consultations with Dr. DeSouza in 2003, the employee reported continued symptoms in her shoulder and some numbness in her right hand. He diagnosed neck and right shoulder pain. At an examination on September 24, 2003, the employee reported that she had consulted Dr. Holmes and that her first rib was dislocated and had been snapped back into place by Dr. Holmes. She reported that she had experienced relief from that treatment for approximately one week, but noted recurrent symptoms thereafter. At that point, Dr. DeSouza recommended a work hardening protocol.
The employee underwent physical therapy at the New Ulm Medical Center from October 7, 2003, through March 8, 2004. When she began that series of treatments, the employee was participating in a work hardening program with the employer, where she had continued to work since her 2002 injury. She reported sharp pain on the right with neck movement and shoulder motions. Examination findings included swelling in the supraclavicular area and tenderness in the muscles in the right side of her neck. Her treatment included mobilization of the cervical spine and first rib as well as use of kinesiotaping to decrease muscle spasm.
The employee continued to work for Kraft through November 20, 2003. She remained off work during the following two years; evidently the employer paid temporary total disability benefits to the extent of the statutory maximum of 104 weeks. Dr. DeSouza reexamined the employee on November 24, 2003, at which time she reported a sharp pain over her right shoulder and a lump which had been reduced frequently in physical therapy after which her pain improved. Dr. DeSouza noted tenderness over the right acromioclavicular joint. He found good neck mobility, negative impingement sign, and no instability of the right shoulder. Dr. DeSouza=s impression at that point was subluxation of the right first rib, as diagnosed by Dr. Holmes.
The employee has continued to obtain medical treatment from Dr. Holmes; by February 2004, he discussed the possibility of surgical stabilization of the first rib, or possibly prolotherapy. She has also consulted Dr. Peter Hanson of Sports and Orthopedic Specialists. In February 2004, Dr. Hanson=s examination revealed tenderness over the first rib as well as over the second and third ribs, and he advised that the first rib was subluxed. At that time, the employee reported that she continued to receive physical therapy at the New Ulm Medical Center, although the records do not indicate with what frequency she received treatments. Dr. Hanson referred the employee for an evaluation by Dr. David Blake, a cardiothoracic surgeon, and also recommended a course of physical therapy, which the employee evidently attended at the Sister Kenney Institute of Abbott Northwestern Hospital. Those treatments apparently were not particularly helpful in relieving the employee=s symptoms.
Dr. Holmes referred the employee to Mr. Mark Bookhout for physical therapy. He initially evaluated her on May 27, 2004, and treated her through July 19, 2004, at which time his notes reflect that the employee had not made significant progress during therapy and that her right shoulder symptoms persisted.
Dr. Holmes=s re-evaluation of the employee in July 2004 reflected that the employee continued to note right shoulder symptoms; at that point, he discussed a functional capacity evaluation (FCE) and possible chronic pain program. On September 7 and 8, 2004, the employee underwent a functional capacities evaluation at Wenger Physical Therapy. According to the report issued by the physical therapist who conducted the FCE, the employee cooperated with attempting each test asked of her, but she did not consistently work to her maximum abilities and demonstrated an inconsistent performance on various tests. The therapist listed the employee=s significant abilities as being AGood upper extremity coordination bilaterally,@ and AAble to tolerate a wide variety of work positions.@ She listed the employee=s significant deficits as being AUpper extremity weakness and mobility limitations due to pain complaints.@ The therapist concluded that it was difficult to determine whether the results of the FCE accurately represented the employee=s true physical abilities. At an examination on October 30, 2004, Dr. Holmes stated that he felt the inconsistencies on the FCE were due to the employee=s unstable first rib. He referred her for a surgical consultation to consider a permanent fixation of the right first rib.
On November 19, 2004, the employee consulted an orthopedic surgeon, Dr. David Blake. The employee reported tenderness in the right trapezius area, clavicular head and acromioclavicular joint. Dr. Blake concluded that the employee=s neurologic status was intact; an x-ray taken showed that her rib structure was normal. Dr. Blake assessed symptoms consistent with thoracic outlet syndrome, and recommended a surgical removal of the right first rib.
Dr. Raih reexamined the employee on January 11, 2005, at the request of the employer. Dr. Raih concluded that, based upon the employee=s symptoms as well as based upon the opinions of Drs. Hanson and Blake, the employee had a form of clinical thoracic outlet syndrome. Dr. Raih found no clinical evidence of rib subluxation, but commented that Acertainly with thoracic outlet syndrome the first rib comes into play and can impinge on the brachial plexus.@ Dr. Raih concluded that, given the chronicity of her problem dating back to the injury, it would be reasonable for Dr. Blake to proceed with the first rib resection and decompression of the brachial plexus. He concluded that the employee had not reached MMI from her work injury, and therefore it was not yet appropriate to rate permanent partial disability. He commented, however, that a surgical alteration or removal of a rib or ribs, such as was proposed for the employee, would result in a rating of 0% permanent partial disability of the whole body.
On March 2, 2005, Dr. Blake surgically removed the employee=s right first rib. His surgery notes stated that the brachial plexus seemed to be intact; a discharge summary noted that the employee=s condition was improved.
The employee has undergone follow-up EMGs since that surgery, as well as at least one MRI scan. Post-surgery, she underwent additional physical therapy, at the Queen of Peace Hospital in New Prague, Minnesota.
In a report dated January 20, 2006, Dr. Holmes assigned the following permanency ratings totaling 35.5% permanent partial disability of the body as a whole:
1. 15%, relative to the brachial plexus, pursuant to 5223.0400, subp. 5D(2); 5223.0400, subp. 3D.
2. 8%, relative to the limited range of flexion or extension in the right shoulder, based upon Minn. R. 5223.0450, subp. 4A(1)(d);
3. 8%, relative to the limited range of abduction or adduction in the right shoulder, shoulder, pursuant to Minn. R. 5223.0450, subp. 4B(1)(c);
4. 4.5% relative to incomplete loss of ulnar motor function, based upon Minn. R. 5223.0400, subp. 5D(2) and 5223.0400, subp. 2C(2);
5. 0% relative to her rib, pursuant to Minn. R. 5223.0440, subp. D(1).
On July 26, 2006, Dr. Holmes amended his permanency ratings to also include an additional 5% permanency rating, based upon ulnar sensory loss, pursuant to Minn. R. 5223.0410, subp. 6(D)(2) and Minn. R. 5223.0410, subp. 2H(1). The ratings assigned by Dr. Holmes totaled 40.5% whole body impairment; the total permanency rating claimed by the employee at the hearing was 34.7288%, based on the statutory formula used to calculate permanent partial disability ratings for multiple body parts, found in Minn. Stat. § 176.105, subd. 4. See Respondent=s Exhibit 5.
On June 9, 2006, the employee returned to work for a new employer, Burger King. The employee testified that she initially worked as a cashier, and later was promoted to the position of production leader. She reportedly worked within restrictions of no lifting greater than seven pounds, with no repetitive use of the right upper extremity.
On August 17, 2006, the employee underwent an independent medical examination with Dr. David Fey, at the request of the employer. Following his review of medical records and his examination, Dr. Fey concluded that the employee had sustained soft-tissue sprain/strain injuries to her left trapezius and potentially her right trapezius and neck. He considered her condition to be a resolving neck and shoulder strain. He found no objective evidence that she had sustained any traumatic first rib subluxation as a result of her 2002 injury. Dr. Fey explained that
The employee=s examination is extremely difficult to interpret given the complex nature of her complaints, as well as her symptom exaggeration. Based on the objective findings of the recent electro myelogram performed in 2005, there is indication that she has a neurologic abnormality involving the right upper extremity. For this reason, it would be appropriate to place her on restrictions of light-duty work. In my opinion, no restrictions are in anyway related to claimed work injury of October 3, 2002.
Dr. Fey concluded that there was no assignable permanent partial disability rating for the employee=s injury. He found no objective evidence to support the diagnosis of a subluxed first rib related to the work injury. He concluded that, if the surgical procedure of the resection of the right first rib was considered to be related to the employee=s work injury, he would concur with Dr. Raih=s assessment that she sustained a 0% permanent partial disability. This is the same PPD rating assigned by Dr. Holmes for the employee=s rib condition.
As to the other permanency ratings assigned by Dr. Holmes, Dr. Fey disputed those ratings. He did not relate the diagnosis of a subluxed first rib, nor any of the EMG findings, to the employee=s 2002 work injury. In Dr. Fey=s opinion, the employee=s motor strength and sensory exam findings were highly subjective and highly difficult to interpret, which raised further questions concerning the permanency opinions offered by Dr. Holmes. Dr. Fey concluded that the employee had reached MMI from her October 3, 2002, work-related injury and that she required no additional medical care or treatment to cure or relieve the effects of any injuries she sustained on October 3, 2002.
On November 7, 2005, the employee filed a claim petition, which she later amended, seeking payment for permanent partial disability benefits, requesting an authorization for an MRI scan and physical therapy, and seeking an authorization for exploration of retraining. The employer denied liability for the claimed benefits. The employer also advised that it had authorized an MRI scan and had paid for all appropriate physical therapy. According to information provided in the appellate briefs, the parties have since reached an agreement on the retraining or rehabilitation issue.
On September 21, 2006, the employee=s claim petition was addressed at an evidentiary hearing before Compensation Judge Carol A. Eckersen. In her Findings and Order served and filed on November 20, 2006, the compensation judge denied the employee=s claims for permanent partial disability benefits and for additional physical therapy. The employee appeals.
STANDARD OF REVIEW
When an appeal is taken from a compensation judge=s factual findings, this court=s review on appeal is limited to a determination of whether the judge=s findings and order are Aclearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. § 176.421, subd. 1(3). If, on the other hand, the judge=s factual determinations are adequately supported by substantial evidence, and not clearly erroneous, we must affirm. This court is not a finder of fact, and on appeal the court will not Aretry@ the factual issues which were before the lower court; thus, it is irrelevant whether different conclusions than those found by the compensation judge could also be reached on the evidence. Substantial evidence supports the findings if, in the context of the record as a whole, they Aare supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where the evidence conflicts or more than once inference may reasonably be drawn from the evidence, the findings must be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Factfindings may not be disturbed, even though this court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Id.
The issues for our consideration are whether substantial evidence in the record supports the findings of the compensation judge that: (1) the employee has sustained no rateable permanent partial disability as a result of her October 3, 2002, injury; and (2) the employee is not entitled to additional physical therapy, for two reasons - - that additional physical therapy does not represent reasonable and necessary treatment that is causally related to her 2002 injury and that the employee has not satisfied the requirements of the treatment parameters which would allow additional therapy beyond the amount allowed by the parameters.
Before addressing those issues, we would first note that it is the compensation judge=s responsibility, as trier of fact, to consider the competing medical opinions and to resolve conflicts in expert testimony. The judge=s decision in that regard will not be reversed so long as the accepted opinion has adequate foundation. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); Smith v. Quebecor, 63 W.C.D. 566 (W.C.C.A. 2003). In the present case, the issues identified above revolve substantially around the judge=s resolution of such conflicts. We reiterate that it is not this court=s function to assess whether substantial evidence might support a conclusion contrary to that reached by the compensation judge; our function on factual review is to assess whether substantial evidence exists to support the conclusion actually reached by the judge. See Redgate v. Sroga=s Standard Serv., 421 N.W.2d 729, 734, 40 W.C.D. 948, 957 (Minn. 1988).
Foundation for Expert Medical Opinion
The employee argues that the opinions of Dr. Fey, and by inference Dr. Raih, cannot serve as adequate support for the compensation judge=s conclusions, in part because they were consulting physicians and were not treating physicians. We reject the argument that Drs. Raih and Fey were unqualified to render opinions concerning either the employee=s permanent partial disability ratings or entitlement to additional physical therapy. Both took a history from the employee in which she described her symptoms, medical history and her work activities for the employer, and both reviewed the employee=s medical records and performed an examination. As a general rule, this level of knowledge is sufficient to afford foundation for the opinion of a medical expert. Drews v. Kohl=s, 55 W.C.D. 33 (W.C.C.A. 1996). The decision concerning the weight to be given to evidence submitted at the hearing, and whether to accept or reject an expert's opinion, is for the compensation judge, not this court. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). Here, the compensation judge accepted Dr. Raih=s and Dr. Fey=s opinions. Their opinions were adequately founded and the compensation judge could reasonably rely upon them. That Drs. Raih and Fey were not the employee=s treating physicians goes to the weight of their opinions, not to competency, and was for the compensation judge to consider along with all other evidence in the record. On this record we cannot say the compensation judge's decision was unsupported by substantial evidence.
In addition, in her brief, the employee alleges that the employer, through its counsel, was purposely trying to deny her rightful entitlement to benefits by consulting a physician Awho works in a >non-clinic atmosphere, doing only IMEs yet claiming to be an orthopedic surgeon.=@ There is no evidence in the record of a defect in the professional qualifications of the independent medical examiners.
Furthermore, the employer had a statutory right to consult Dr. Raih and Dr. Fey. The Minnesota Workers= Compensation Statutes, at sections 176.135 and 176.155, address a party=s right to consult a physician. For example, the employee was availed of her statutory right to choose her treating physician, when she changed her treatment to Dr. Holmes. See Minn. Stat. § 176.135, subd. 2. In addition, the employer paid for the expenses related to the employee=s consultation with Dr. Drake for a second opinion concerning the necessity of surgery. See Minn. Stat. § 176.135, subd. 1a. The statute provides a corresponding right or opportunity to an employer and insurer to require an employee to submit to an examination with a physician of their choosing, and at reasonable times thereafter if requested by the employer and insurer. See Minn. Stat. § 176.155. The employer in this case was within its statutory rights to schedule examinations with Drs. Raih and Fey.
Claim for Permanent Partial Disability Benefits
The employee appeals from the denial of her claims for permanent partial disability benefits, relying on the opinion of Dr. Holmes and the ratings he assigned. The compensation judge concluded that the employee has not sustained any permanent partial disability (PPD) as a substantial result of her October 3, 2002, injury. In her decision, the compensation judge explained the basis for her findings. At Finding 10, 11 and 12, the compensation judge outlined the medical opinions of Drs. Holmes, Raih and Fey, and the PPD ratings they assigned. In her memorandum, the judge compared those ratings to the requirements set forth in the Workers= Compensation Permanent Partial Disability Schedules. At Finding 13, the compensation judge determined that the employee had not sustained any PPD relative to her shoulder condition, brachial plexus condition and ulnar nerve motor and sensory loss, and also explained that she did not find Dr. Holmes=s opinion to be persuasive on the issue of PPD.
A compensation judge is responsible for determining under which rating category an employee=s disability falls, based on all relevant evidence, including objective medical findings. Jensen v. Best Temporaries, 46 W.C.D. 498, 500-501 (W.C.C.A. 1992). The employee argues that it was her attending physician who must determine the level of her PPD, and that the employer has the burden to prove that the assigned rating should either be lowered or denied. We disagree. In order to receive a permanent partial disability rating, the employee must prove each element of the scheduled disability. Knudson v. Twin City Hide, Inc., 40 W.C.D. 336, 338 (W.C.C.A. 1987) (citing Davies v. Marriot-Host Int=l, 39 W.C.D. 631, 633 (W.C.C.A. 1987)). It is not the employer=s responsibility to disprove an employee=s claim for PPD. And, although permanency ratings offered by physicians may assist a compensation judge in making this determination - - whether those ratings are assigned by treating or consulting physicians - - such opinions are not binding on a compensation judge. See Erickson by Erickson v. Gopher Masonry, Inc., 329 N.W.2d 40, 43, 35 W.C.D. 523, 528 (Minn. 1983). A compensation judge=s finding regarding the rating of permanent partial disability is one of ultimate fact and must be affirmed if it is supported by substantial evidence. Jacobowitch v. Bell & Howell, 404 N.W.2d 270, 274, 39 W.C.D. 771, 778 (Minn. 1987).
Dr. Holmes assigned a combined permanency rating of 34.7288% permanent partial disability of the body as a whole, based on the employee=s brachial plexus, right shoulder and right ulnar nerve conditions. At the time that Dr. Raih examined the employee, he concluded that it was then premature to assign a permanency rating. He did conclude, however, that if the employee underwent the proposed rib resection surgery, that procedure would result in a 0% permanency rating. Dr. Fey concurred with that assessment, and found no other conditions that qualified the employee for any permanency ratings under the Minnesota Permanent Partial Disability Schedules. The compensation judge did not find Dr. Holmes=s opinion concerning permanent partial disability to be persuasive, and concluded that the evidence did not show that the employee had the requisite medical condition necessary to qualify her for the various ratings assigned by Dr. Holmes.
We have carefully reviewed the record, including the medical records offered as exhibits at the hearing, and the testimony presented by the employee at the hearing. Because substantial evidence in the record supports the judge=s conclusion that the employee has not sustained any permanent partial disability to the whole body as a result of her work injury, the judge=s findings concerning PPD are affirmed. Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
Claim for Additional Physical Therapy Under the Medical Treatment Parameters
The compensation judge concluded that the evidence did not demonstrate that the employee is entitled to a departure from the treatment parameters which would allow additional physical therapy. The employee appeals from the compensation judge=s denial of her claim for payment of additional physical therapy. Before her surgery in 2003, she underwent periodic sessions of physical therapy. After her March 2005 surgery, she underwent physical therapy at Queen of Peace Hospital for approximately 14 or 15 months, and requests that authorization for therapy be extended on an ongoing basis. The employee argues that the employer=s denial of ongoing physical therapy has led to a deterioration in her condition, amply proving that she needs the therapy to maintain function in her right hand, arm and shoulder. She contends that her trial testimony and the records of Dr. Holmes support the conclusion that her physical therapy has been effective in maintaining her functional status. Although not specifically articulated in the employee=s appellate brief, she argues that her medical condition entitles her to a departure under the treatment parameters to allow for additional physical therapy.
Under legislation enacted with the objective of controlling medical costs in the workers= compensation system, the Minnesota Department of Labor and Industry promulgated treatment parameter rules for health care provider treatment. Hirsch v. Bartley-Lindsay Co., 537 N.W.2d 480, 483, 53 W.C.D. 144, 148 (Minn. 1995). The applicable parameter in this case, Minn. R. 5221.6200, subp. 3, limits the number of treatments an employee can receive for passive treatment modalities. Subpart 3A of that rule provides that passive treatment is generally limited to twelve weeks, except as provided in subpart 3B of the rule, and it is uncontested that the employee=s physical therapy exceeded that duration. Subpart 3B of the rule outlines the factors that must be met in order to allow additional physical therapy treatment beyond the initial twelve weeks, and states as follows:
B.(1) An additional 12 visits for the use of passive treatment modalities over an additional 12 months may be provided if all of the following apply:
(a) the employee is released to work or is permanently totally disabled and the additional passive treatment must result in progressive improvement in, or maintenance of, functional status achieved during the initial 12 weeks of passive care;
(b) the treatment must not be given on a regularly scheduled basis;
(c) the health care provider must document in the medical record a plan to encourage the employee=s independence and decreased reliance on health care providers;
(d) management of the employee=s condition must include active treatment modalities during this period;
(e) the additional 12 visits for passive treatment must not delay the required surgical or chronic pain evaluation required by this chapter; and
(f) passive care is inappropriate while the employee has chronic pain syndrome.
(2) Except as otherwise provided in part 5221.6050, subpart 8, treatment may continue beyond the additional 12 visits only after prior approval by the insurer, commissioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining employability; if the employee is permanently totally disabled, or if upon retirement the employee is eligible for ongoing medical benefits for the work injury, treatment may continue beyond the additional 12 visits only after prior approval by the insurer, commissioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status.
The parties acknowledge that the employee=s therapy has exceeded twelve weeks. The employee asserts that she needs ongoing physical therapy, referring to Minn. R. 5221.6200, subp. 3B(2), that provides for passive treatment beyond the presumptively allowed twelve weeks plus twelve visits, Abased on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status.@ In support of her claim, the employee relies on the opinions of Dr. Holmes and Ms. Marie Fishel, physical therapist at Queen of Peace Hospital.
In her report of August 15, 2006, Ms. Fishel concluded that the employee needed additional physical therapy for continued improvement in her right shoulder, neck and right upper extremity range of motion and strength. Ms. Fishel noted that the physical therapy had helped control the employee=s pain and swelling and had allowed her to work a 40-hour per week job. In his report of September 6, 2006, Dr. Holmes outlined factors that demonstrate the employee=s entitlement to a departure from the treatment parameters= limitation. He explained that the employee had a medical complication - - surgery to resect her first rib - - and also required physical therapy to assist with her return to work. He also opined that the employee had continued to show progress in physical therapy, had returned to a full-time job, and had continued to show a need for physical therapy with her reintroduction to the workplace. Referring to the requirements in the treatment parameters for a departure from the limitations on treatment, Dr. Holmes determined that the employee,
had the documented medical complication requiring surgery, as well as flare-ups due to the stoppage of her treatment. She has required the additional treatment to assist her return to work as this is increasing stress on her neck and arm. She continues to show improvement in subjective, objective and functional status as demonstrated in the medical records, including PT notes.
The compensation judge determined that the employee was not entitled to payment for additional physical therapy treatments. In her memorandum, the compensation judge explained the basis for her denial. She outlined Dr. Holmes=s explanation for his recommendation for additional physical therapy treatments, and then outlined factors in the employee=s medical records which contradicted Dr. Holmes=s opinion that therapy had effectively improved the employee=s condition. The judge commented that
[t]he employee=s subjective complaints remain at a high level. She continues to have pain in the range of 7 to 8 out of a possible 10. She has not increased her function significantly and her objective findings are unchanged in the medical records.
The judge also noted that even though Dr. Holmes had advised that physical therapy had resulted in Acontinuous improvement,@ he did not indicate specifically what improvement had been made.
The judge concluded that the employee had not established a basis for a departure from the treatment parameters, as would be required under Minn. R. 5221.6200, subp. 3B(2). She was not persuaded by Dr. Holmes=s opinion that a basis exists to allow a departure from the limitations in the treatment parameters and that additional physical therapy is reasonable or necessary. We conclude that the record as a whole, including the employee=s medical records and the opinions of Dr. Fey and Raih, support the compensation judge=s conclusions. Because it was not unreasonable in light of the entire record, we affirm the compensation judge=s factual conclusion that the employee did not satisfy the departure provisions of Minn. R. 5221.6050, subp. 8A, and Minn. R. 5221.6200, subp. 3B. We therefore affirm the judge=s decision. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
The employee also contends that the employer improperly discontinued its payments for therapy treatments, both by failing to file a Notice of Intent to Discontinue (NOID), and by failing to advise of the denial for ongoing treatment within her initial twelve weeks of therapy. The employee argues that A[t]he regs are very clear that if the employer-insurer is going to invoke the rule the action has to be initiated before the end of the first 12-week period so that it can be determined whether another 12-week period is in order.@ She contends that she will need physical therapy for the rest of her working life in order to maintain a maximum amount of mobility in her arm. In addition, the employee contends that the compensation judge improperly Aplaced the burden of proof upon Dr. Holmes who prescribed the treatment whereas the burden of proof should have been placed upon [the self-insured employer] as it was a prescribed medical treatment.@
The employer was not required to file a NOID in order to discontinue payment for physical therapy treatments. Under Minn. Stat. § 176.238, a NOID is required under certain circumstances to discontinue payment of wage loss benefits; there is no reference in that portion of the statute to cessation of payment for medical treatment. In addition, there is no legal requirement that, in order to maintain its right to invoke the limitations on physical therapy outlined in the medical treatment parameters, an employer must challenge an employee=s entitlement to ongoing physical therapy within the first twelve weeks of treatment.
The judge=s factual conclusions are well supported by substantial evidence. Included in that evidence is Dr. Fey=s opinion that the employee requires no additional medical treatment to cure and relieve the effects of any injuries she sustained as a result of the October 3, 2002, incident. Regardless of whether disputed medical treatment is governed by the treatment parameters or analyzed under Minn. Stat. § 176.135 and long-standing case law principles, the reasonableness and necessity of any given medical treatment is a question of fact for the compensation judge. See Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993). In this case, the judge analyzed the disputed treatment under case law principles and under the guidelines of treatment parameters specifically enacted to aid a trier of fact in determining appropriate treatment. Having reviewed this record in its entirety, we conclude that substantial evidence in the record supports the judge=s finding that the treatment at issue was not reasonable and necessary to cure or relieve the effects of the work injury. Accordingly, we affirm that denial of payment for additional physical therapy.
In her appellate brief, the employee has expressed her mistrust of the workers= compensation system, and has made various allegations of fraud, misdealings, and untruthful statements on the part of court personnel, counsel, and independent medical examiners. We have carefully reviewed the record and are not persuaded by the employee=s allegations. In addition, this court=s authority generally does not extend to review or consideration of the kind of the allegations and comments made by the employee in her appellate brief. See Minn. Stat. § 176.421, subd. 6. We have considered the employee=s legal arguments in her brief, her testimony at the hearing, and the medical records and other exhibits in the record. Based on our review of the entire record, including written documents submitted into evidence at the hearing and the testimony and arguments presented at the hearing, we conclude that the compensation judge=s decisions on the various issues are well-supported by the evidence in the record. The decision of the compensation judge, therefore, is affirmed in its entirety. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
 Portions of the medical background information outlined in this decision were obtained from summaries in various medical reports, and from the employee=s testimony, as the record does not contain all of the actual chart notes or reports generated for treatment dates listed in this decision.
 Subluxation is defined as an incomplete or partial dislocation. Dorland=s Illustrated Medical Dictionary 1719 (29th ed. 2000).
 Based on Minn. R. 5223.0440, subp. 2D, which states, in part, as follows:
D. Ribs, costal cartilage, and rib musculature, disorder, dislocation, fracture, or surgical alteration or removal of:
(1) rib or ribs, zero percent.
 It is not clear from the evidence in the record as to when the physical therapy treatments ended, but the parties referred to 14-15 months of therapy in the hearing record.
On appeal, the court has not considered the documents attached to the employee=s brief. The court=s review on appeal is limited to the evidence submitted to the compensation judge. See Gollop v. Gollop, 389 N.W.2d 202, 38 W.C.D. 757 (Minn. 1986); Vagts v. Tromco Electric, 48 W.C.D. 622 (W.C.C.A. 1993).