CHAD A. POLECHECK, Employee/Appellant, v. STATE, DEP’T of NATURAL RESOURCES, SELF-INSURED, Employer, and BLUE CROSS/BLUE SHIELD OF MINN. & BLUE PLUS, ST. LUKE’S CLINICS, and SMDC HEALTH SYS., Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
OCTOBER 5, 2009
CAUSATION - PSYCHOLOGICAL CONDITION. Substantial evidence, including medical expert opinion, supports the compensation judge’s findings that the employee’s admitted left shoulder work injury is not a substantial contributing cause of his depression, sleep disorder, and adjustment disorder, and that the employer does not suffer from post traumatic stress disorder.
REHABILITATION - RETRAINING. Substantial evidence supports the compensation judge’s determination that obtaining a bachelor’s of social work through the University of Wisconsin - Superior would return the employee to the economic status he would have enjoyed but for his personal injury, and his denial of the employee’s request for more expensive retraining through the College of St. Scholastica.
MEDICAL TREATMENT & EXPENSE. Where the compensation judge made two apparently inconsistent findings regarding payment of medical expenses related to the employee’s admitted left shoulder injury, the denial of certain expenses is vacated, and the parties are directed to attempt to resolve payment of the claims as directed in the prior finding.
Affirmed in part and vacated in part.
Determined by: Johnson, C.J., Wilson, J., and Stofferahn, J.
Compensation Judge: Gregory A. Bonovetz
Attorneys: Ronald R. Envall, Cuzzo & Envall, Duluth, MN, for the Appellant. James A. Froeber, MMB/Employee Ins., St. Paul, MN, for the Respondent.
THOMAS L. JOHNSON, Judge
The employee appeals the compensation judge’s finding that the employee’s admitted work injury was not a substantial contributing cause to the development of depression, a sleep disorder, or an adjustment disorder, the award of a retraining program at the University of Wisconsin - Superior rather than a program at the College of St. Scholastica, and the denial of certain drug expenses. We affirm in part and vacate in part.
Chad Polecheck, the employee, was hired by the Minnesota Department of Natural Resources, the employer, in late 2004 or early 2005 as a Conservation Officer/Game Warden. To qualify for this position, a candidate must successfully complete a six-month skills training program held at Camp Ripley, Minnesota. On March 3, 2005, during his training, the employee sustained a personal injury arising out of his employment. On that date, the employer was self-insured for workers’ compensation liability. The employer admitted liability for the employee’s personal injury.
As a part of the training program, the employee took part in defensive skills training which was conducted in a gymnasium at Camp Ripley. In this training, candidates were pitted against instructors in combative situations. An individual candidate and an instructor engaged in the defensive tactics training while the other candidates encircled the two combatants holding large square pads intended to protect the combatants from striking the pillars in the gymnasium. On March 3, 2005, the employee was taking part in this training and was one of the persons encircling the two combatants. During the course of the training, the instructor apparently swung his left arm backward, inadvertently striking the employee’s left shoulder, and dislocating the shoulder to the front. The employee testified that his left shoulder popped out in front but immediately popped back into place.
The employee was taken to the emergency room in Little Falls, Minnesota, after his injury. X-rays were taken and the employee’s left arm was placed in an immobilizer. The employee saw Dr. Philip Prosapio who diagnosed a probable posterior shoulder dislocation with a possible superior and posterior labral tear. On April 20, 2005, the employee was examined by Dr. Graham Ritts at Orthopaedic Associates of Duluth, who diagnosed a possible posterior subluxation of the shoulder. The employee stated he wanted a conservative treatment program and Dr. Ritts agreed. The doctor stated, however, that surgery might be necessary.
The employee continued with his training program with the employer after his personal injury. Approximately one week after his shoulder injury, the employee sustained a knee injury during a running exercise but did not report the knee injury for fear of losing his job. Thereafter, the employee continued with the training program performing physically strenuous activities. On August 25, 2005, the employer terminated the employee’s job. The employee contends he was terminated because he was physically limited in what he could do because of his shoulder and knee injuries. The employer contends the employee’s performance was deficient in areas unrelated to his ability to perform the physical duties of the job. The employee testified that when his job was terminated he was devastated because his dream was to be a conservation officer.
In September 2005, Dr. Ritts performed a left reverse Bankart repair and SLAP repair. In January 2006, Dr. Ritts noted the employee was having continuing problems with his left shoulder and was struggling with physical therapy. A cortisone injection provided only minimal relief and Dr. Ritts recommended a second surgery. On March 9, 2006, Dr. Ritts performed an open posterior capsular shift for posterior, inferior, and multi-direction instability of the left shoulder. Thereafter, the doctor ordered physical therapy.
The employee testified that the second shoulder surgery in March 2006 did not improve his functional ability and made his symptoms worse. In addition to significant pain, the employee stated he experienced grinding, squeaking, and occasionally his shoulder would lock in a fixed position. The employee stated his shoulder pain and problems caused an inability to sleep which, in turn, affected his ability to concentrate and function during the day. The employee testified the constant waking and sleeplessness during the night caused him to have violent nightmares. He stated he would have dreams about painful situations in which he was being attacked and had to defend himself or his family against someone entering their home. The employee testified that when he realized the second surgery was not successful, he felt he no longer had control of his future. The employee stated his shoulder also affected his family life. He testified he was short-tempered and irritable, unable to lift or carry his daughter, unable to contribute to the family chores, could not cook or dress himself, and could barely drive. This inability to function put a burden on his wife, family, and parents, and caused “a very low self-esteem in the sense of a great loss of self-worth.” (T. 82.)
On May 11, 2006, Dr. Ritts stated the employee had associated depression and chronic pain with his left shoulder and wished to consider vocational retraining and rehabilitation. Dr. Ritts referred the employee to Dr. Elizabeth Weinmann, who examined the employee on May 25, 2006. The employee complained of continuing left shoulder pain since March 3, 2005, stated he slept poorly, his shoulder pain was worse in the mornings, and the shoulder ached when he drove a car, reached, or lifted with his left arm. Dr. Weinman noted the employee had been depressed and anxious because of his loss of function and work and because he realized he would have to make a significant career shift. The doctor diagnosed status post SLAP repair of the left shoulder with chronic pain, impaired range of motion, adjustment disorder, and depression due to pain and loss of function. A physical therapy program was instituted in June 2006. The employee reported no improvement in his left shoulder pain and continued difficulty sleeping. Dr. Weinman referred the employee to Dr. Monica Miles for a psychiatric consultation and noted the employee also had an appointment with a psychologist at the Duluth Clinic.
The employee saw psychologist Susan Bruns at the Duluth Clinic on July 10, 2006. The employee reported chronic left shoulder pain and loss of functional abilities including difficulty with lifting, dressing, grooming, reaching, sleeping, recreational activities, driving, housework and yard work. The employee also expressed a significant sense of loss of a dream because of his inability to complete his training with the employer for the conservation officer/game warden position. Ms. Bruns diagnosed an adjustment disorder with mixed depression and anxiety and instituted psychotherapy. By report dated January 3, 2008, Ms. Bruns’ diagnosis remained adjustment disorder with mixed depression, anxiety, and post traumatic stress disorder (PTSD).
The employee saw Dr. Miles on October 5, 2006. The employee reported chronic left shoulder pain, symptoms of insomnia, irritability, inability to focus, sadness, a lack of well being, and anger. The employee stated his anger was directed toward the fact that he lost his dream job as a game warden as a result of his injury and that he felt unfairly treated. Dr. Miles diagnosed adjustment disorder with mood and conduct disturbance and mood disorder secondary to chronic pain. Dr. Miles prescribed Ambien for sleep, Cymbalta for depression, and Clonazepam for anxiety. In March 2007, the doctor’s diagnosis was adjustment disorder with depressed mood, post traumatic stress disorder, and sleep disorder secondary to pain syndrome. In January 2008, the employee reported to Dr. Miles that he had continuing left shoulder pain and had to decrease his work hours because of the lack of pain control. Dr. Miles noted the employee had
really severe PTSD where he has nightmares and also avoidant behaviors. He often awakens stressed and diaphoretic. He tries to get his body and mind to relax but much of the time without success. He is uncomfortable in groups because he is afraid someone might bump the shoulder. He has flashbacks of his injury and fears reinjury. Once again, he has the avoidant behavior and the anxiety associated with his fears.
Dr. Miles further reported:
The patient’s affect changes when he talks to me about the fact that this injury has caused him a change in life with his child. That is, his daughter is now 2 years old and he still cannot pick her up. He cannot cross country ski or participate in some of the activities he has done in the past. He is limited to picking up less than 20 pounds at the time.
. . . However, it becomes dysthymic and almost tearful when talking about the loss of function, particularly with his child and family life. We talked about the fact, though, how chronic pain and how it affects his sleep can certainly effect on his mood and ability to function.
(Pet. Ex. W.)
Dr. John Rauenhorst, a psychiatrist, examined the employee on June 18, 2008, at the request of the self-insured employer. The doctor obtained a history from the employee, reviewed medical records, and performed a mental status evaluation. Dr. Rauenhorst diagnosed adjustment disorder with mixed anxiety and depressed mood, but stated the employee did not have a diagnosis of post traumatic stress disorder. Dr. Rauenhorst stated:
The physical trauma he describes likely would not have been sufficient to provoke a Posttraumatic Stress Disorder. Further, he did not have the intense emotional reaction to the event, which is needed for this diagnosis. Lastly, he does not have the intrusive recollections of the event, which are hallmark of this disorder.
(Resp. Ex. 2.) The doctor opined the employee’s loss of his job as a game warden was a substantial contributing factor to the development of the adjustment disorder. In addition, the employee’s concerns about his financial situation, his workers’ compensation litigation, and his concern about future employment and future financial prospects were also significant contributing factors to the development of an adjustment disorder. Dr. Rauenhorst opined the March 3, 2005, left shoulder injury was not a direct cause of the employee’s adjustment disorder.
The employee was examined by Dr. Joseph Sivak, a psychiatrist, in September 2008, at the request of the employee’s attorney. Dr. Sivak obtained a history from the employee, reviewed the employee’s medical records, administered psychometric tests, and conducted a mental status examination. Dr. Sivak diagnosed post traumatic stress disorder and depression, which the doctor opined resulted from the physical injury, the physical pain, and the loss of functioning caused by the employee’s personal injury. The doctor disagreed with Dr. Rauenhorst’s opinion that the trauma suffered by the employee was insufficient to trigger the onset of PTSD. Rather, Dr. Sivak opined that the Diagnostic Statistical Manual criteria for PTSD were clearly satisfied under the undisputed facts of the injury. The doctor stated:
[I]n terms of the traumatic event being significant enough, although the patient did not die and no one was killed, by definition from the DSM IV criteria 1A - the person experienced, witnessed or else confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. Certainly, patient’s physical integrity was threatened and this was considered a serious injury. He could not move his shoulder well. He was helpless. It is compelling that he did not see the blow coming, it was unexpected, he went to his knees, he has blocked out part of the trauma and his very identity was in his physical prowess and now his left shoulder was injured in a place where you have to show extreme levels of prowess and even in a situation of fighting this certainly has fulfilled criteria 1A.
(Pet. Ex. I.)
In a supplemental report dated February 2, 2009, Dr. Rauenhorst reviewed some additional medical records including the June 18, 2008, report of Dr. Sivak. Dr. Rauenhorst stated he disagreed with Dr. Sivak that the employee has a post traumatic stress disorder and opined the traumatic event sustained by the employee was not severe enough to meet the criteria of the Diagnostic Statistical Manual for the diagnosis of PTSD.
Dr. Rauenhorst went on to state:
In discussing his injury with me, Mr. Polecheck showed virtually no affect. The affect which he showed during the interview, i.e. more intense emotion, feelings of anxiety, indications of tenseness, and expression of depression and apprehension were present when discussing his financial concerns, his concerns about his future, and his loss of job at the DNR, not about the injury itself.
Further, it is unlikely that Mr. Polecheck would have been able to continue with the session that day, much less with the training over the ensuing days, were he to have experienced an event and emotional reaction such as described in DSM IV.
Dr. Rauenhorst again concluded the employee does not have a post traumatic stress disorder and stated his symptoms are a result of an adjustment disorder, “which is a reaction to his loss of his job, the current litigation, and his uncertainty about the future.” (Resp. Ex. 3.)
The employee has restrictions caused by his personal injury that preclude him from returning to the field of law enforcement. The respondent provided the employee with rehabilitation services. The employee conducted a reasonable and diligent job search but was unable to locate appropriate employment. The parties agree that a course of retraining to obtain a bachelor’s of social work degree (BSW) is appropriate for the employee. The only dispute between the parties is what school the employee should attend to obtain the BSW degree.
The employee chose to attend the College of St. Scholastica in Duluth, Minnesota. The employee and Jean Anderson, his qualified rehabilitation coordinator (QRC), evaluated all of the schools in the area that offer a BSW degree multiple times over a three year period. The employee personally visited the University of Minnesota Duluth (UMD), College of St. Scholastica (CSS), and University of Wisconsin - Superior (UWS), and met with placement personnel at each school. The employee determined the coursework that would be required at each college, spoke with people in the community about the reputation of each college, and discussed the merits of each with his QRC. The employee testified he had specific concerns with UWS, which he concluded was less accommodating than the other schools and failed to return phone calls or follow up on meeting requests. Ms. Anderson testified she encountered similar difficulties. The employee testified CSS was much more accommodating than UWS, was better prepared for the meeting, and more readily provided the needed information. The curriculum at CSS includes an Encore program, a specific program for older non-traditional students such as the employee. The employee and Ms. Anderson testified the Encore program at CSS was important for a returning student like the employee and increased his chance of success in completing the retraining plan. Ms. Anderson testified that unlike CSS, UWS did not offer any kind of placement assistance. The employee testified that CSS had superior placement ratings and made a greater effort after graduation to assure their graduates were employed. Finally, the employee testified that at CSS, he could transfer more of his prior credits from UMD.
Alden Bjorklund, a qualified rehabilitation consultant, conducted a vocational evaluation of the employee at the request of the employer, prepared a report, and testified at the hearing. Mr. Bjorklund opined the plan to retrain the employee as a social worker was appropriate but the question was which school to attend. Mr. Bjorklund testified he contacted the UWS staff without difficulty and spoke with several administrators and professors involved in the social work program. He concluded the employee would be able to complete the full requirements of the BSW at UWS within three or four semesters based on approximately 12 credits a semester. Mr. Bjorklund stated both schools are accredited through the North Central Association of Colleges and Schools and the Council on Social Work Education, and a BSW graduate of both schools is eligible to sit for the necessary certification and licensure examinations. Mr. Bjorklund opined a BSW from UWS would have equal weight as a degree from CSS at a lower cost. He testified that the cost at CSS was $15,162.00 a semester or approximately $55,000.00 for four semesters or $70,500.00 for five semesters. At UWS, the cost for four semesters was approximately $12,300.00 or $15,500.00 for five semesters.
Following a hearing, the compensation judge found that since the fall of 2005, the employee has experienced bouts of depression, sleeplessness, and an adjustment disorder. The compensation judge found the development of these three psychological conditions was substantially caused by the employee’s loss of his dream job as a game warden. The compensation judge found the employee’s left shoulder injury was not a substantial contributing cause of the development of depression, a sleep disorder, or an adjustment disorder, and found the employee does not suffer from post traumatic stress disorder. The compensation judge found a retraining program leading to a bachelor’s degree in social work was appropriate, found the degree at the CSS was substantially more expensive than the program at the UWS, and found the latter program would return the employee to an economic status he would have had but for his personal injury at a lower cost. Accordingly, the compensation judge ordered the self-insured employer to pay the employee the reasonable costs of obtaining a bachelor’s of social work degree at the University of Wisconsin - Superior. The employee appeals.
1. Nature and Extent of Injury
The compensation judge found the employee’s left shoulder injury was not a substantial contributing cause of the development of depression, a sleep disorder, an adjustment disorder or post traumatic stress syndrome. Rather, the judge found that it was the employee’s loss of his dream job that was the basis for the employee’s development of depression, anxiety, and an adjustment disorder. These findings, the employee argues, are not supported by the record. The employee asserts the judge’s findings are contradicted by the testimony of the employee and by medical evidence, including the opinions of Dr. Sivak, Dr. Miles, Ms. Bruns, and Dr. Weinman. The appellant contends the judge disregarded the bulk of the medical evidence in concluding that the employee’s loss of function, chronic pain, and difficult recovery from two failed surgeries played no part in the development of these medical conditions. Rather, the employee argues, a reasonable reading of the medical records as a whole points to the fact that the employee’s mental problems originated from constant chronic pain, his inability to sleep through the night, recurrent nightmares, loss of his ability to function, and his loss of a desired career in law enforcement. Since all of these conditions resulted from the personal injury, the employee contends they are compensable.
There is substantial, credible evidence in the record to support the employee’s claim that he developed post traumatic stress disorder and/or depression and/or a sleep disorder as a result of his March 3, 2005, personal injury. This evidence includes the testimony of the employee and the records and reports of Ms. Bruns, Dr. Miles, and Dr. Sivak. Under this court’s standard of review, however, the issue is not whether the evidence will support alternative findings, but whether substantial evidence supports the compensation judge’s decision. In applying this standard, the court looks not only at the evidence that supports the judge’s findings, but also at the opposing evidence and the evidence from which conflicting inferences might be drawn. The evidence, in a sense, must be weighed to determine its substantiality. The substantial evidence standard is “admonition to the reviewing court not to treat the findings of the fact finder lightly, while at the same time the reviewing court remains cognizant of its own responsibility to exercise good judgment in reviewing what the evidence will reasonably sustain.” Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). In this case, we conclude there is substantial evidence in the record to support the judge’s decision.
Dr. Rauenhorst diagnosed the employee as having an adjustment disorder with mixed anxiety and depressed mood. The doctor opined, however, that it was not the employee’s left shoulder injury that was the cause of the employee’s adjustment disorder. Rather, Dr. Rauenhorst concluded the employee’s loss of his job as a game warden, concerns about his financial situation, his workers’ compensation litigation, and concerns about future employment and future financial prospects were the significant contributing factors to the development of the adjustment disorder. Dr. Rauenhorst further opined the employee did not have a post traumatic stress disorder because he did not have the intense emotional reaction to the event which was needed for the diagnosis under the Diagnostic Statistical Manual. Dr. Rauenhorst had adequate foundation for his opinions and the compensation judge could reasonably rely upon them. The doctor’s testimony constitutes substantial evidence for the compensation judge’s decision.
The employee contends the compensation judge focused exclusively on the employee’s loss of a job as a game warden while ignoring all of the other collateral effects of the injury. We disagree. In a thorough and extensive memorandum, the compensation judge stated:
With regard to the Court’s denial of the employee’s claimed psychological conditions, the Court is not saying the employee does not suffer from depression or from an adjustment disorder but that the left shoulder injury was not a substantial contributing cause. As the Court has reviewed all of the evidence, both the employee’s testimony at hearing as well as the extensive medical records the Court is struck by the great importance the employee had placed on becoming a game warden. As he indicated, since childhood this was his dream job. Everything he had done was leading to a position with the DNR. It was the employee’s loss of his dream, his termination from the training program that so drastically affected his psyche. As the employee testified, with his being terminated based on his superior’s determination that his performance was “less than acceptable,” with his supervisor advising him in the letter of August 25, 2005, that even with additional time he could not raise his “performance to a satisfactory level,” the employee experienced an intense “loss of self worth, loss of self esteem.” As Dr. Sivak indicated the employee advised him he always wanted to work for the DNR; it was a life long dream to be a game warden. Further as Dr. Sivak indicated when the DNR let him go, “he was sad and humiliated and felt awful.”
As for the affect which the left shoulder injury may have had on the employee’s psychological condition it is clear that it was not the left shoulder injury that so markedly affected the employee but the fact that he had lost his dream. He could not become a game warden. Bitter and feeling victimized the employee, as Dr. Sivak pointed out, experienced a tremendous sense of unfairness and injustice, a sense of victimization. Further the records go on to indicate the employee himself refused to accept, refused to believe that his termination was not due to his left shoulder condition. As both Dr. Sivak’s report points out as does Dr. Rauenhorst’s, the employee firmly believed that the reason he did not pass the probationary period was solely because he had sustained a left shoulder injury. Although the letter of August 25, 2005, makes no reference of a physical inability to perform the duties, although that letter specifically refers to the fact that the employee’s performance was not acceptable, that he did not improve in spite of discussions which his supervisors had with him and although David Rodahl, testifying on behalf of the Department, clearly and cogently explained that the employee having been terminated had nothing to do with his physical abilities but centered on concerns over the employee’s sense of judgment, his inability to complete various tasks and the inappropriate choices made by the employee, still the employee focuses on the left shoulder as being the sole cause of his termination. Obviously the employee’s loss of his “dream job” has had a profound affect on his psyche. However it was not the left shoulder injury that has caused the psychological conditions; it was his loss of his long hoped for position.
As an aside, a close review of all of the evidence clearly establishes that the employee does not suffer from post traumatic stress disorder. As the evidence clearly establishes, at the time the employee’s left shoulder was injured he himself was not involved in the physical training activity with the instructor. He was not in the ring sparring with the instructor. Rather he was one of the observers - one observing a training session in a very controlled environment. As described, there is no intimation of a threatening environment, there was no indication even from the employee’s testimony of any sense of intense fear or helplessness or horror. In fact as the employee described the occurrence of the injury, he had his back to the instructor. He did not even observe the mechanism by which his left shoulder was injured. This comports with what the employee told Dr. Sivak as reflected in Dr. Sivak’s report where he notes the employee “does not remember some specific details of the actual injury.” In any event as the Court has specifically found, the left shoulder injury of March 3, 2005 was not a substantial contributing cause of any psychological problems from which the employee may be suffering, whether depression, sleep disorder, adjustment disorder or post traumatic stress disorder.
(Mem. at 10-11.)
It is evident from the compensation judge’s memorandum that he carefully considered the testimony of the employee together with all of the medical evidence in the case in concluding that the personal injury was not a substantial contributing cause of any psychological problems from which the employee may be suffering. Because that decision is based on substantial evidence, it must be affirmed. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).
The compensation judge found a retraining program leading to a bachelor’s degree in social work was appropriate, found the degree at CSS was substantially more expensive than the program at UWS, and found the latter program would return the employee to an economic status he would have enjoyed but for the personal injury at a lower cost. The employee acknowledges that the program at CSS is approximately $25,000 to $31,000 more expensive but contends that the CSS program offers options and a flexibility not available at UWS. The employee points to the Encore program at CSS which is specifically tailored to older, non-traditional students, superior placement ratings at CSS, the better reputation of CSS in the community, the fact that CSS will accept more of the employee’s prior credits, and the employee’s experience that CSS was more accommodating and responsive than UWS. These considerations, the employee contends, evidence that the programs are not equal and, therefore, cost should not be the only factor. Accordingly, the employee argues the compensation judge’s decision should be reversed. We are not persuaded.
In Varda v. Northwest Airlines Corp., 692 N.W.2d 440, 65 W.C.D. 92 (Minn. 2005) this court reversed an award of a 4-year retraining in nursing that cost approximately $144,000 and substituted a 2-year nursing program costing approximately $10,000. On appeal, the supreme court noted the evidence was essentially undisputed that both the 2-year and 4-year retraining programs would provide a job that would return the employee to an economic status equal to or higher than her pre-injury status. The court noted the critical question was whether the more costly 4-year program was necessary to increase the likelihood of reemployment within the meaning of Minn. Stat. § 176.102, subd. 1(b). The court stated that because the undisputed facts showed that the 2-year program would restore the employee to an economic status higher than she enjoyed before the disability, the question before the court was one of law. The court stated the fact that the 4-year program could be even more beneficial than the 2-year program did not establish that it was necessary within the meaning of the statute. Accordingly, the supreme court affirmed this court’s denial of the 4-year program and award of the 2-year program.
Admittedly, the difference in cost between the competing programs is not nearly as large here as it was in the Varda case. Further, as the compensation judge recognized, there are some differences between the two programs. However, both programs are accredited and provide a BSW degree. Mr. Bjorklund opined the two programs had equal weight in terms of job qualifications and if the employee presented himself well in interviews, he would be competitive with any other equally educated applicant. We find no evidence that a degree from UWS would not allow the employee to attain the economic status he would have had but for the disability resulting from his work injury. The compensation judge found that either program would accomplish that statutory purpose and substantial evidence supports this conclusion. Accordingly, under Varda, the compensation judge correctly concluded that a comparison of the costs was a significant factor. The judge noted that the program at CSS was at least $25,000 and possibly as much as $50,000 more expensive than the program at UWS. Substantial evidence supports a determination that the two programs are essentially equal, but that the CSS program is substantially more expensive than the UWS program. The compensation judge’s decision, therefore, is affirmed.
3. Medical Expenses
At the hearing, the compensation judge received into evidence, without objection, Employee Exhibit A, an itemization of the employee’s claim for medical mileage and prescription expenses paid by the employee. In finding 4, the compensation judge found:
Since at the hearing of February 19, 2009, counsel for the self-insured employer agreed that his client will pay/reimburse any charges for the care and treatment of the left shoulder it is anticipated that counsel for the employee and counsel for the self-insured employer will review the content of Petitioner’s Exhibit A and agree as to those entries pertaining to the left shoulder.
In finding 33, the compensation again made reference to Petitioner’s Exhibit A and identified two specific charges for treatment by Dr. Kaiser. The compensation judge then found:
All other items contained within Petitioner’s Exhibit A refer to care and treatment for which the self-insured employer is not responsible under the provisions of the Minnesota Workers’ Compensation Act.
On appeal, the employee contends findings 4 and 33 are in conflict. Contained within Exhibit A are claims for the drugs Ambien, Trazadone, Celebrex, Tramadol and Ibuprofen. The employee contends the Ibuprofen, Celebrex, and Tramadol were prescribed to treat the employee’s pain resulting from the left shoulder injury, and the Ambien and Trazadone were prescribed to treat the employee’s sleep problems that resulted from shoulder pain. The employer contends the Ambien and Trazadone were prescribed to treat a sleep disorder which the compensation judge found was not a compensable result of the injury. Further, the employer contends the employee failed to prove the Ibuprofen, Celebrex, and Tramadol were reasonable and necessary medical expenses necessary to treat the employee’s shoulder condition. Accordingly, the employer requests this court affirm the compensation judge’s denial of the claimed medical expenses.
It is difficult to discern the compensation judge’s intent in view of the apparent conflict between the two findings. As the employee notes, there is evidence of record that Ibuprofen, Celebrex, and Tramadol were prescribed for pain which the employee related to his left shoulder injury. Ambien and Trazadone were prescribed for the employee’s sleep difficulties which the compensation judge found to be a non-compensable condition. There is evidence, however, the employee experienced sleep problems that resulted from his shoulder pain.
We vacate the last sentence of finding 33 and affirm finding 4. Counsel for the parties should review Petitioner’s Exhibit A in an attempt to resolve payment of those entries, if any, pertaining to the left shoulder. If the parties are unable to agree, the employee may file a medical request.
 The criteria from the Diagnostic Statistical Manual for PTSD are that a person be exposed to a traumatic event in which both of the following are present:
The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others.
The person’s response involved intense fear, helplessness, or horror.
(Resp. Ex. 3, p.2.)