Westling v. Untiedt Vegetable Farms

BRADLEY L. WESTLING, Employee/Appellant, v. UNTIEDT VEGETABLE FARMS, and FLORISTS MUTUAL GROUP, Employer-Insurer/Cross-Appellants, and RIDGEVIEW MEDICAL CTR., CENTER FOR DIAGNOSTIC IMAGING, HOWARD LAKE PHARMACY, HUTCHINSON AREA HEALTH CARE, PRIMARY BEHAVIORAL HEALTH CLINIC, INC., and RIDGEVIEW CLINICS BUSINESS OFFICE, Intervenors.

CAUSATION. Where no medical opinion provided a causal relationship between the employee=s work injury and his chronic pain syndrome and depression, substantial evidence did not support the compensation judge=s decision.

Attorneys: Richard C. Lund, Law Offices of Donald F. Noack, Mound, MN, for the Appellant. Richard L. Plagens, Lommen, Nelson, Cole & Stageberg, Minneapolis, MN, for the Cross-Appellants.

The employee has appealed from the compensation judge=s denial of his claim for permanent partial disability. The employer and insurer have cross-appealed the compensation judge=s determination of a causal relationship between the employee=s admitted work injury and various psychological conditions. We reverse the compensation judge=s causation determination.

In May 1999, Bradley Westling, the employee, was employed by Untiedt Vegetable Farms in a variety of duties including driving truck, doing greenhouse maintenance, and planting and caring of crops. On May 17, 1999, the employee visited Ridgeview Clinic where he saw a physician=s assistant with complaints of swelling and pain in his left forearm. He was given medication and warm moist packs and a diagnosis of cellulitis. He returned to the clinic two days later with symptoms of increasing pain and was referred to Dr. Robert Heeter, an orthopedist.

Dr. Heeter saw the employee on May 19, 1999, and noted diffuse induration and swelling in the left forearm and pain with excursion of his left fingers. He admitted the employee to the hospital on that date for observation and for administration of antibiotics while a final diagnosis was determined. The employee received an MRI in the hospital which showed edematous changes in the left forearm and the employee was treated with antibiotics. He was discharged on May 22 with a diagnosis of tenosynovitis. He returned to his family doctor at Ridgeview Clinic, Dr. Kevin White, on May 25 with continued swelling in his left forearm and was given steroids to help with the inflammation.

On June 1, 1999, the employee saw Dr. H. Martin Dvorak at Ridgeview Clinic. The swelling in the forearm appeared to be resolving and Dr. Dvorak noted that Ahis only other complaint today is both shoulders have been aching for the past six months. A little worse on the left than the right. He does not know the cause of this.@ Dr. Dvorak continued the employee=s medications.

On June 11, 1999, the employee saw a rheumatologist, Dr. Paul Waytz at the recommendation of Dr. Heeter. The employee gave Dr. Waytz a history of bilateral shoulder pain with a sensation of grinding ache for the past six months and a history of insidious onset of swelling and soreness in his left forearm. Dr. Waytz noted the treatment to date and found forearm swelling on exam. Dr. Waytz made no assessment but prescribed further blood tests as well as a bone scan. When the employee returned to the Ridgeview Clinic on June 14, he still had left forearm discomfort with numbness and tingling in his fingers. The employee was transferred to Hennepin County Medical Center for further diagnostic work up. Those records are not in evidence.

The employee returned for additional treatment with Dr. Heeter and on June 23, 1999, the employee was admitted to the hospital for surgery. On June 24, Dr. Heeter performed an exploration of the left forearm with synovectomy of the forearm, wrist and hand of all flexor tendon units. The employee was discharged with a diagnosis of Aproliferative synovitis flexor compartment left forearm.@ The surgery did not resolve the employee=s complaints and on July 29, 1999, he saw Dr. Dvorak at Ridgeview with continued swelling in his left forearm. The employee advised Dr. Dvorak that his symptoms were better when he was on steroids but that once he stopped the medication his symptoms returned. Dr. Dvorak assessed granulomatous synovitis of the left forearm and possible left sarcoid. He ordered diagnostic testing and placed the employee back on steroids and prescribed additional medication for the possible sarcoid.

When the employee returned to Dr. Dvorak on August 10, he still had swelling and pain in his left forearm. Dr. Dvorak summarized the employee=s care and stated, AHe has had two MRIs that show that this is related to the soft tissue, connective tissue, muscle, ligaments, tendons. He has had a biopsy that showed caseating and non-caseating granulomatous area. Fungal cultures have been negative. All laboratory work up including for sarcoid, rheumatological disorders, biopsies for any sarcoma or tumor, or any other infectious process including sed rate, CBC, and any other musculoskeletal problems that can be readily identified has been negative.@ Dr. Dvorak recommended referring the employee to another hand specialist, another rheumatologist, and an infectious disease specialist. The employee was admitted to the hospital on September 8, 1999, by Dr. Dvorak with worsening inflammation in the left forearm. By that time, the employee had seen the infectious disease specialist who was considering a diagnosis of sporotrichosis, a fungal disease.^[1] On September 11, Dr. Heeter performed an exploration of the volar compartment of the left forearm and plantar aspect of the hand with fluid, synovial, and tissues being harvested for analysis.

Biopsy results confirmed the existence of sporotrichosis and the employee was placed on medication for that condition. Significant improvement in his condition was noted when he returned to see Dr. Dvorak on November 2, 1999, and only mild edema and discomfort were noted in his left forearm. On that date the employee also advised Dr. Dvorak that he was experiencing discomfort in his left hip, left knee, and right shoulder. Physical examination for those complaints was negative except for tenderness noted by the employee and discomfort with range of motion testing. Dr. Dvorak believed the symptoms represented musculoskeletal aches and pains which would be treated with anti-inflammatories and ibuprofen. The employee returned to Dr. Dvorak on November 22 and reported continued improvement in his left forearm symptoms.

Dr. Gary Kravitz did a review of the employee=s medical records on behalf of the employer and insurer in March 2000. In his report of March 24, 2000, Dr. Kravitz concurred in the diagnosis of sporotrichosis and stated that the condition was related to the employee=s work. Dr. Kravitz noted that the sporothrix fungus which leads to the condition is difficult to grow in a laboratory setting and concluded that the care and treatment received by the employee to that date was reasonable and necessary. Dr. Kravitz stated that further treatment would not be necessary for the sporotrichosis after the drug therapy ended.

On March 29, 2000, the employee saw Dr. David Nerothin at the Ridgeview Medical Center Pain Clinic at the referral of Dr. White. The employee=s chief complaint was noted as being Aleft forearm pain and dysfunction, but now more recently low back pain again, left-sided with hip, knee and foot pain and weakness.@ The employee provided a history of low back pain for more than 20 years which had been diagnosed as a herniated disc on the basis of CT scans and which had required hospitalization for treatment. Dr. Nerothin recommended Neurontin and Amitriptyline for pain relief.

On the employee=s third visit to the clinic on April 26, 2000, Dr. Nerothin spoke on the telephone with doctors treating the employee for sporotrichosis and was advised that the infection was over. The employee reported to Dr. Nerothin that he was Adoing better and better all the time@ and that the residual pain in his low back and left leg were better. He had very little symptomatology in his left shoulder, although he continued to have right shoulder pain that Ahe has had forever.@ The employee continued to complain of polyarthralgia of his knees and elbows. Dr. Nerothin performed an L4-5 steroid block and continued the medication he had prescribed previously. Dr. Nerothin also stated AThe patient should obviously continue with his Zoloft.@ There is no indication in the records as to when the employee started on Zoloft, which doctor prescribed it, or for what condition. No records of further treatment at the pain clinic are in evidence.

On May 23, 2000, the employee saw Dr. White for chest pain. There was no other complaint made at that time. On June 6, the employee returned to Dr. White for a follow-up on his chest pain. He also referred to left knee pain and wondered if his sporotrichosis was a factor in that symptom. He advised Dr. White that Dr. Waytz was of the opinion that this was due to degenerative joint disease based on x-rays which showed degenerative changes. Finally, he discussed depression with Dr. White, who increased the employee=s Zoloft prescription from 50mg to 100mg per day.

The employee next treated on July 18, 2000, when he saw Dr. White. The history recorded by Dr. White was that the employee had developed a Asevere arthropathy@ for eight months to a year with pain in his left ankle, left knee, left hip, right shoulder worse than his left shoulder. On exam, Dr. White found no joint swelling, no erythemia, no joint warmth, a full range of motion in his joints, and crepitus in both knees consistent with degenerative joint disease. Dr. White stated that the employee Awill see a psychiatrist in Hutchinson@ and Dr. White also concluded that the employee Amay need to go to Mayo Clinic in the near future.@

On July 26, 2000, the employee saw Dr. John Bohrod for psychiatric evaluation at the referral of Dr. White. Dr. Bohrod diagnosed major depressive disorder, single episode, moderate to severe. Dr. Bohrod placed the employee on Wellbutrin and Trazodone. He provided no causal opinion although he referred to the employee=s Amore than one year history of battling first the medical problem of unknown etiology and then of difficulty in obtaining relief, particularly from chronic pain and concern about his future ability to function.@

The employee returned to Dr. White on August 29 with complaints of increased joint pain in his left knee which caused it to give out almost on a daily basis. Examination showed good mobility in his joints except for his left shoulder which had crepitation. Dr. White assessed continued multiple joint aches with Aetiology unclear at this time@ and reactive depression.

The employee was seen on a number of occasions at Mayo Clinic beginning in November 2000. Partial records from those visits are in evidence including the chart notes from the employee=s consultation with Dr. Steven Ytterberg in rheumatology on January 12, 2001. Dr. Ytterberg noted a history of having seen the employee on Aseveral occasions@ for evaluation of joint symptoms. The employee and his wife had Amultiple questions about whether sporotrichosis was the trigger of all of this.@ Dr. Ytterberg did not find any evidence of inflammatory changes in the joints and stated AI am not concerned about active sporotrichosis as the cause of his joint pain.@ Evaluation at Mayo had revealed meniscus damage in his left knee and the employee had undergone arthroscopic surgery for that condition. Dr. Ytterberg=s final diagnoses were:

The employee continued to treat with Drs. White and Dvorak for what was described as chronic multiple joint pain. On May 8, 2001, Dr. White noted the employee was upset with his care at Mayo and the diagnosis of degenerative joint disease. Dr. White commented, AI believe that this is somehow related to sporotrichosis infection; however, we were unable to find any evidence serology wise, radiologically wise, or clinical of the employee=s joint pain.@ Dr. White also noted the employee was working full-time. Dr. White continued the employee=s Neurontin and also prescribed Vicodin for night time use. On May 29, 2001, the employee was complaining of right forearm pain which Dr. Dvorak assessed as being lateral epicondylitis. The employee was taken off work by Dr. White to avoid repetitive use of his right arm and because of vision changes associated with the higher dosage of Neurontin he was taking.

The employee received an infectious disease consultation with Dr. Perry Severance on July 10, 2001, for evaluation of Aa progressively worsening generalized arthralgia and myalgia syndrome with a past history of sporotrichosis.@ Dr. Severance took a detailed history from the employee but there is no evidence that he had available any of the employee=s previous medical records. Dr. Severance=s impression included that of Adiffuse musculoligamentous tenderness and pain syndrome of undetermined etiology.@ Dr. Severance concluded, AAt this point I do not have the foggiest idea what is causing this gentleman=s specific complaints. I do not think that it relates to direct involvement with sporotrichosis and I am unaware of sporotrichosis precipitating a reactive arthropathy and in fact there is no evidence that he has had a true arthritis associated with this process.@

The employee continued to treat with Drs. Dvorak and White for his joint pain. On July 20, 2001, he saw Dr. White with a new complaint that his right knee had been giving out and that he needed a cane. Dr. White noted the employee had been on Wellbutrin for depression in the past and decided to start him on Zoloft because of recurrent depression symptoms.^[2] Dr. White concluded the employee was completely disabled because of his Apolyarticular joint pains.@ At his October 9, 2001 appointment with Dr. White, the employee=s Zoloft was increased to 100mg a day and the employee was referred back to the pain clinic. The employee apparently saw Dr. Nerothin again and was given a TENS unit. There are no records in evidence from these visits. On December 4, Dr. White indicated that he wanted to send the employee to another infectious disease specialist.

The employee saw Dr. Steven Dittes on January 9, 2002. Dr. Dittes took a detailed history and discussed the employee=s situation with one of his doctors at Mayo. Dr. Dittes was advised that tests at Mayo were negative for sporotrichosis. After the exam, Dr. Dittes concluded that disseminated sporotrichosis was Ahighly unlikely@ but recommended arthroscopic surgery of the left shoulder to do a synovial biopsy. The arthroscopic surgery was done on February 6, 2002, by Dr. Heeter and the biopsy showed no indication of sporotrichosis.

On January 21, 2002, Dr. Kravitz generated a report following a second medical record review he provided for the employer and insurer. Dr. Kravitz concluded that the employee had made a full recovery from sporotrichosis and that he did not have disseminated sporotrichosis. Dr. Kravitz found no relationship between the employee=s joint complaints and his previous fungal disease. Dr. Kravitz also noted Aa marked disparity@ between the subjective complaints of the employee and the findings on examination. Dr. Kravitz recommended a psychiatric evaluation.

The employee had initially filed a claim petition in November 1999 for a left arm infection which was alleged to have occurred on May 17, 1999, and which resulted in medical expense. The parties entered into an agreement in August 2000, in which the employer and insurer admitted the sporotrichosis as being work related and agreed to pay wage loss and medical expense related to that condition. The employee filed a medical request on August 4, 2000, for payment of prescription co-pays and a rehabilitation request on January 24, 2001, for a rehabilitation consultation. These claims were consolidated but stricken from the calendar at the request of the employee on April 12, 2001. On May 24, 2001, the employee filed a claim petition for wage loss benefits, medical expenses and rehabilitation services. On March 23, 2003, an order was issued which consolidated the medical request filed August 8, 2000, the rehabilitation request filed January 29, 2001, the claim petition filed May 31, 2001, a medical request filed by the employee on April 4, 2002, a request for formal hearing filed by the employer and insurer on November 1, 2002, and an amended claim petition filed by the employee on February 19, 2003.

Dr. White wrote a report of November 29, 2003 to the employee=s attorney. In that report, Dr. White stated, ABrad=s symptoms seem to be quite subjective in nature in that he does not really have significant clinical findings of arthropathy such as erythemia, crepitus, joint swelling. His blood work does not demonstrate any phase reactivity that would go along with an inflammatory arthritis.@ Nevertheless, Dr. White diagnosed arthropathy and in responding to the issue of causation, he stated, AI do not think that there is an expert in the medical field out there that can give you a proper answer whether his debilitation is due to the original sporotrichosis.@

Dr. John Cronin, a licensed psychologist, prepared a report dated January 6, 2003 regarding the employee. In that report, Dr. Cronin refers to treating the employee but no treatment records are in evidence. Dr. Cronin diagnosed the employee under DSM-IV as 307.89, pain disorder associated with both psychological factors and a general medical condition and 296.00, major depressive disorder.^[3] Dr. Cronin concluded that the employee=s depression was reactive and Aa response to the various physical conditions and problems that he sustained as a result of his work related injuries.@ Dr. Cronin provided the employee with a rating of 50 percent of the whole body and stated AIt is obvious that Mr. Westling is suffering from multiple physical and psychological/psychiatric problems that appear to be work related in origin.@

In a follow-up report of January 13, 2003, Dr. Cronin stated that the employee was permanently totally disabled and noted AMr. Westling continues to have significant physical problems that I am obviously not qualified to comment regarding the severity and limitations thereof, and as a result has developed some very significant psychological and psychiatric issues including a chronic pain syndrome.@

The employee was evaluated at the request of the employer and insurer by Dr. Thomas Gratzer, a psychiatrist, who saw the employee on April 9, 2003, and who prepared a 36 page report, of which 17 pages are a summary of the employee=s medical and psychological care after May 17, 1999. Dr. Gratzer=s psychiatric diagnosis was of pain disorder associated with psychological factors. Dr. Gratzer did not attribute the pain disorder to physical problems since, based on his review of the medical records, the employee=s doctors had not been able to find a physical basis for his pain complaints. Dr. Gratzer concluded that the diagnosed pain disorder was not related to the employee=s work injury, finding that Athe functional aspects of his pain disorder are related to pre-existing characterological dynamics and secondary gain factors.@ Dr. Gratzer also concluded that the employee=s depression was not related to his injury.

The consolidated claims of the parties were heard by Compensation Judge James Cannon on June 26, 2003. The record remained open until July 21, 2003, and on September 18, 2003, the compensation judge issued his Findings and Order. The compensation judge determined that the employee=s work injury was a substantial contributing factor in the development of the employee=s psychological depression, chronic pain syndrome, and polyarthralgia, or multiple joint pain. The compensation judge denied the employee=s claims for wage loss benefits and denied the employee=s claim for permanent partial disability. The compensation judge also ordered payment of various medical providers. The employee has appealed the denial of his claim for permanent partial disability benefits. The employer and insurer have cross-appealed the causal determination and the award of medical expenses.

DECISION

The compensation judge determined that the employee=s fungal disease, sporotrichosis, was a substantial contributing fact in the development of the employee=s depression, chronic pain syndrome, and polyarthralgia. The employer and insurer have appealed this determination, arguing that there is no medical opinion providing the necessary causal relationship between the employee=s work injury and these diagnoses. We agree.

While formal medical opinions as to causation are not necessarily required to support a finding of compensability in those cases which involve Acommoner afflictions,@ we have determined that, in cases which are medically complex, a properly founded medical opinion providing a causal relationship is necessary. Bender v. Dongo Tool Co., 509 N.W.2d 366, 367, 49 W.C.D. 511, 513 (Minn. 1993); Miller v. Abbott Northwestern Hosp., slip op. (W.C.C.A. July 17, 2001); Reeder v. Metro Transit, slip op. (W.C.C.A. September 11, 2003). We conclude as a starting point that the diagnoses in this case are such that there must be a medical opinion to establish a causal relationship between these conditions and the employee=s work injury.

We consider first the diagnosis of polyarthralgia or multiple joint pain. According to Dr. Kravitz, in a small number of cases, sporotrichosis can result in disseminated sporotrichosis, a situation in which the fungal disease migrates to the major joints of the body and in which the joints then become inflamed and swollen. It is apparent from the evidence that the employee was convinced that his joint pain was due to disseminated sporotrichosis. In response, his primary care physicians ordered multiple evaluations by infectious disease specialists and rheumatologists. No doctor ever found an indication that the sporotrichosis was a causative factor for the joint pain. Dr. Kravitz stated specifically that the employee did not have disseminated sporotrichosis because the employee=s joints did not show the redness or swelling which would be associated with disseminated sporotrichosis. The employee=s joint pain was consistently subjective on examination. No basis for the pain was ever found in any of the radiologic scans, blood tests, biopsies or any other diagnostic tests performed on the employee. The employee received no treatment for sporotrichosis after April 2000.

No consulting or treating doctor has ever provided a medical opinion that the employee=s subjective pain complaints were related to sporotrichosis. The doctors at Mayo Clinic attributed the employee=s pain to a left knee meniscus tear and to degenerative arthritis. Dr. Severance concluded that he didn=t have Athe foggiest idea@ as to the cause of the employee=s complaints. Dr. Dittes believed that the disseminated sporotrichosis was Ahighly unlikely.@ Dr. White concluded in his November 29, 2002 report that he was unable to state that the pain was due to sporotrichosis.

There are also doctors who saw the employee but whose records are not in evidence. Dr. Gratzer provided summaries of some of those consultations in his April 9, 2003 report. The employee was apparently seen by Dr. Stein at the Minneapolis Clinic of Neurology in March 2000 with complaints of shooting pain and numbness from his left hip to his foot and pain from his left shoulder into his left hand. A cervical MRI showed degenerative changes and stenosis at C3-4. Dr. Stein opined that it was unlikely that the employee=s neurological symptoms were related to sporotrichosis. The employee returned to Dr. Waytz on September 14, 2001, who apparently concluded that the employee had some sort of Aunusual pain syndrome.@ The employee saw Dr. Nerothin on October 15, 2001 with pain in every joint which was increased with activity. Dr. Nerothin diagnosed Apolyarticular pain of unknown etiology.@

While the employee had pain complaints that occurred after his sporotrichosis, a temporal relationship is not the equivalent of a causal relationship. The employee had a twenty plus year history of low back pain due to a herniated disc, a history of bilateral shoulder pain in June 1999 which had existed for six months, foraminal stenosis at the C3-4 level as confirmed by an MRI scan, lateral epicondylitis in his right arm, and degenerative joint disease which necessitated left knee surgery. In the absence of a medical opinion, there is no reason to attribute the employee=s ongoing pain to sporotrichosis, a condition which had resolved, instead of one of these other ongoing conditions.

Given the medical evidence of record, the only conclusion which can be reached is that the employee had subjective pain complaints with no physical connection to the previous diagnosis of sporotrichosis. The label which best fits the employee=s situation is chronic pain syndrome. There is no basis for identifying this condition as polyarthralgia, which suggests a physical condition. The question is whether there is a medical opinion which provides a causal relationship between the employee=s resolved fungal disease and his chronic pain syndrome.

Chronic pain syndrome is not a psychiatric diagnosis found in the DSM-IV but is defined in the treatment parameter rules as a condition which includes a complaint of enduring pain which is not consistent with a known organic syndrome which has remained untreated.^[4] We conclude that a clear medical opinion is necessary to connect this psychological condition to a work injury. As the Minnesota Supreme Court said in considering the causal relationship of an employee=s depression to his work injury in Rindahl v. Brighton Wood Farms, Inc., 382 N.W.2d 855, 856, 38 W.C.D. 473, 475 (Minn. 1986), AWe do not think causation in this complex and subtle area of emotional distress is entirely a matter of logic, for it does not necessarily follow that because the depression came after the injury that the injury caused the depression.@

The employee contends that the requisite medical support is provided by Dr. Cronin. Although Dr. Cronin used the phrase Achronic pain syndrome@ in his January 13, 2003, report, it is apparent that Dr. Cronin did not believe that the employee=s pain was due to psychological factors only. In his January 13, 2003, report Dr. Cronin stated, AMr. Westling continues to have significant physical problems that I am obviously not qualified to comment regarding the severity and limitations thereof, and as a result has developed some very significant psychological and psychiatric issues including a chronic pain syndrome.@ (Emphasis added). Essentially, Dr. Cronin concluded that the employee=s chronic pain syndrome was the result of continued physical pain from sporotrichosis. That conclusion was incorrect.

The significance of a physical basis for the employee=s pain to Dr. Cronin is reflected in the diagnosis Dr. Cronin chose to use, pain disorder with associated psychological factors and a general medical condition. (emphasis added) As noted earlier, that diagnosis is from the DSM-IV, diagnosis 307.89. In order for that diagnosis to be correct there must be a medical condition which plays an important role in the severity and maintenance of the pain. See DSM-IV, page 499. For examples of general medical conditions, the DSM-IV refers to various musculoskeletal conditions or neuropathies. See DSM-IV, page 501. Dr. Cronin=s diagnosis then requires not just pain but a physical basis for that pain. As we have discussed above, no physical basis for the employee=s prolonged pain is identified by any physician. Had Dr. Cronin been of the opinion that the employee=s pain was due solely to a psychological condition and that there was no physical basis for the employee=s pain, an alternate diagnosis was available in the DSM-IV. It is the diagnosis used by Dr. Gratzer, pain disorder associated with psychological factors, DSM-IV 307.80, a diagnosis consistent with chronic pain syndrome. Dr. Cronin=s diagnosis is not supported by the evidence.

We consider the last diagnosis, that of depression. The compensation judge based his causation finding, at least in part, on a determination that the employee did not treat for depression until after he had contracted sporotrichosis. While that may be correct, we note again that this temporal relationship does not establish causation and we further note that when the employee saw Dr. Nerothin at the Ridgeview Pain Center in April 2000, he was already using a prescription anti-depressant. What doctor provided this prescription, at what time and for what condition is not in the record. Further, the doctors in this matter who have diagnosed depression, such as Dr. Cronin, have considered the depression to be a reaction to the employee=s chronic pain. In his January 6, 2003, report, Dr. Cronin stated, Ait would be my opinion that this depression is reactive in nature and is a response to the various physical conditions and problems that he sustained as a result of his work related injuries.@ Since we have concluded that substantial evidence does not support a causal relationship between the employee=s chronic pain and his work injury, we must conclude as well that the depression is not related to the work injury.

While it is the function of the compensation judge to choose between competing medical opinions, that choice will not be upheld when the facts assumed by the expert are not supported by substantial evidence. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); Sparks v. Warmka Transport, Inc., 62 W.C.D. 586 (W.C.C.A. 2002), summarily aff=d October 21, 2002.

The decision of the compensation judge is reversed. Given our reversal of the compensation judge=s causation determination the employee=s appeal from the denial of his permanent partial disability claim and the employer and insurer=s cross-appeal from the award of payment to medical providers have been rendered moot and will not be considered.

^[1] Dr. Dvorak=s records refer to Dr. Sabath at Hennepin County Medical Center. No records from Dr. Sabath are in evidence.

^[2] The record does not indicate when the employee stopped the Zoloft he previously had been prescribed.

^[3] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4^th ed. 2000.

^[4] Minn. R. 5221.6040, subp. 3.