The employee appeals from the compensation judge’s denial of the intervention claim of Medical Advanced Pain Specialists on grounds that billings from that intervenor are duplicative of better supported billings from intervenor HealthEast St. John’s Hospital.  We reverse and remand.

As summarized below, Judith Anderson has a long history of both work-related and nonwork-related injuries and treatment, including examination and treatment by more than two dozen different doctors over the course of over twenty-five years.  Over time, her treatment has come to include injection therapy, fusion surgery, physical therapy, branch blocks, long-term medication with several different narcotics, and psychiatric treatment for depression.

On April 28, 1985, and February 15, 1986, Ms. Anderson [the employee] sustained work-related injuries to her low back in the course of her work with Glencoe Regional Health Services.  She was twenty-five years old on the first of those dates, and Glencoe Regional Health Services [Glencoe], which was self-insured at the time, acknowledged liability for the injuries and commenced payment of benefits, ultimately pursuant to a stipulation for settlement that closed out all benefits except future medical and permanent total disability.  On June 19, 1991, September 4, 1991, and January 21, 1992, the employee sustained several additional work-related injuries to various parts of her body, including injuries to her cervical, thoracic, and lumbar spine, all in the course of her employment with M.G. Waldbaum Co. [Waldbaum].  Waldbaum and its insurer admitted liability for these injuries and paid various workers’ compensation benefits, including $32,500.00 pursuant to a full, final, and complete settlement with the employee, executed October 16, 1992, which closed out all benefits except future non-chiropractic treatment expenses.  On November 7, 1994, August 21, 1995, and June 5, 1996, the employee sustained further work-related injuries, these in the course of her employment with Tino’s Italian Specialties [Tino’s].  Tino’s and its insurer admitted liability for low back injuries and paid various workers’ compensation benefits, reimbursed in part by Waldbaum and two other employers, pursuant to a partial stipulation for settlement executed in March and June of 1999, between those three parties, Glencoe, a fifth employer, and the Special Compensation Fund.

Since her injuries with Glencoe, Waldbaum, and Tino’s, the employee has sustained several additional work-related injuries to her low back and/or her neck, and as consequences of a number of nonwork-related motor vehicle accidents.  In March and April of 2002, the employee executed yet another stipulation for settlement, this with Glencoe, Tino’s, two intervenors, and another employer not here a party.  This stipulation provided in part that, “regarding medical benefits only from and after 1/18/02, the claims do remain open as against Glencoe Area/Self-Insured and Tino’s/CNA subject to the provisions of the prior Stipulations for Settlement.”  The employee has not worked since 2005.

On March 6, 2006, the employee commenced treatment with pain specialist Dr. Lon Lutz at HealthEast Midway Pain Center in St. Paul, who is affiliated with Medical Advanced Pain Specialists [MAPS], which serves patients at various locations.  The employee reported to Dr. Lutz continuing lumbar pain at a level eight on a scale of one to ten, and Dr. Lutz diagnosed lumbar degenerative disc disease with history of L4-5 fusion, now with radicular pain into the lower extremities.  In treatment, Dr. Lutz administered medial branch blocks and recommended a change in medication, initiation of a walking regimen, continued use of a TENS unit, and return to the clinic in two weeks.

The employee eventually sought further benefits consequent to her work injuries with Glencoe, Tino’s, Waldbaum, and another employer not here a party, and the matter eventually came on for hearing on August 22 and 23, 2007.  By findings and order filed October 25, 2007, the compensation judge in that proceeding concluded that the treatment at issue to the employee’s low back had been reasonable and necessary to cure or relieve the effects of the employee’s work injuries, and the judge apportioned liability for the cost of that treatment one-third to Glencoe and two-thirds to Tino’s.  The judge further concluded, however, that the employee had not met her burden of proving that the treatment to her neck that was at issue was causally related to any of her work injuries.  Since the October 2007 findings and order, the employee has received considerable medical treatment for her low back and/or her neck from several different providers, for which she has sought further compensation.

On June 12, 2008, the employee was examined at the request of Glencoe by orthopedic surgeon Dr. Nolan Segal.  In his eventual report on October 2, 2008, Dr. Segal indicated in part that he was concerned that the employee’s overall care and treatment had been excessive, that any benefits of her current pool or other physical therapy would be outweighed by the long-distance driving involved, and that her long-term medication with narcotics was not in accordance with the Workers’ Compensation Treatment Parameters.

On June 18, 2008, the employee filed another claim petition, alleging against Glencoe, Waldbaum, and Tino’s entitlement to medical benefits in the amount of $1,293.93, based on work injuries to her neck, left arm, and back with those employers.  On May 11, 2009, she amended that claim petition to allege entitlement to permanent total disability benefits continuing from August 30, 2005, in addition to payment of medical bills from various providers, including HealthEast and MAPS.

On July 31, 2009, the employee was examined for Glencoe by orthopedic surgeon Dr. Paul Yellin, who had also examined the employee for that employer about ten years earlier.  In his report on August 6, 2009, Dr. Yellin diagnosed in part chronic cervical and thoracic pain with L4-5 and L5-S1 disc degeneration, status post L4-5/L5-S1 fusion with residual mechanical low back pain, depression by history, drug dependency, and chronic pain syndrome unresponsive to surgical injections and other conservative modalities.  The following year, the employee and Glencoe apparently entered into another stipulation for settlement regarding the employee’s permanent total disability claim, which did not affect the employee’s claim for medical benefits.

Subsequent to her initial treatment with him for her low back pain in March of 2006, the employee continued to treat with Dr. Lutz and his staff of various certified nurse practitioners and physician’s assistants through at least November 8, 2010.  On March 5, 2009, HealthEast St. John’s Hospital [HealthEast/St. John’s] made application to intervene in the amount of $10,412.88, for services rendered between March 20, 2006, and January 29, 2009, as evident in the Workers’ Compensation Division’s electronic imaging system.  Following a settlement conference on April 23, 2009, hearing in the matter was scheduled for December 15, 2010.  About three weeks before that date, on November 22, 2010, MAPS applied for intervenor status.  The application, as evident in the electronic imaging system, sought payment of a Spaeth balance^[1] in the amount of $7,341.00, for medical services that included treatment by Dr. Lutz at HealthEast Midway Pain Center from July 20, 2009, to November 8, 2010.  On December 3, 2010, Tino’s objected to MAPS’s motion to intervene, indicating that it did not concede that the treatment at issue was causally related to a work injury, was reasonable and necessary with regard to such an injury, or was appropriate under the treatment parameters.  In its objection, Tino’s expressly requested that MAPS be put “to its strict proof thereof” and “be required to appear at all conferences and hearings prepared to submit its proof.”  On December 7, 2010, one week before the hearing, in a letter to the assigned compensation judge and including the same itemization of charges included in MAPS’s application for intervention, MAPS’s workers’ compensation specialist, Juli Lemke, indicated that she would be unable to attend the hearing.

On December 8, 2010, in a letter in reply to the attorney for Tino’s, Dr. Segal indicated that, after review of additional medical records since his October 2008 report, he would not consider the employee’s ongoing care and treatment since June of 2008 completely reasonable or necessary regarding her low back condition.  He noted that the employee’s chronic pain and leg symptoms were not consistent with any radiologic studies or objective findings and that there had been virtually no change in her overall condition in spite of the extensive treatment since that time.  Dr. Segal reiterated his earlier opinion that pool therapy was contra-indicated for the employee, given the long driving that it required, and, recommending again that she be weaned off of narcotic medication, he suggested that she be put on “a religious, careful, active home exercise program.”

The matter came on for hearing on December 15, 2010, on which date the employee was currently being paid both permanent total disability and Social Security disability benefits.  The employee, Glencoe, Waldbaum, and Tino’s were each represented by counsel at the hearing.  None of the apparently six intervenors was represented by counsel.  Issues at hearing, as later identified in the compensation judge’s findings and order, included the following: (1) payment of medical bills; (2) payment and reimbursement to apparently six intervenors - - St. Francis Hospital [St. Francis], HealthEast St. John’s, MAPS, Queen of Peace Hospital [Queen of Peace], Blue Cross and Blue Shield of Minnesota [BC & BS], and apparently HealthPartners;^[2] (3) reimbursement for mileage, parking, and other out-of-pocket expenses related to the obtaining of certain prescription medication, medical treatment, and pool therapy; (4) whether treatment to the employee’s cervical spine was causally related to her work injuries; (5) whether the treatment at issue was reasonable and necessary; and (6) the applicability of the treatment parameters.  In an opening statement of the issues on behalf of the three employers, counsel for Tino’s stated in part that it was the employers’ “position that the employee is not entitled to any reimbursement or payment of the medicals, [and that] the intervenors are not entitled to reimbursement either.”  The specific dollar amounts of the respective intervenors’ claims were not identified in opening arguments.

Evidence submitted at hearing included the employee’s submission of medical records from “HealthEast Pain Care Center” in St. Paul, from “HealthEast Midway Pain Center” in St. Paul, and from various other providers.  The HealthEast pain center records included essentially the same records of Dr. Lutz’s treatment as had been included in MAPS’s November 22, 2010, motion for intervention, plus some earlier treatment records of a Dr. Michael Espeland.  Medical bills submitted into evidence by the employee did not include separate billings by either HealthEast or MAPS.  Also admitted into evidence was testimony from the employee, in part that she had ongoing low back pain, with burning and tingling down her legs, but that treatment to her left arm and right knee seemed unrelated to her work injuries.

By findings and order filed February 3, 2011, the compensation judge concluded in part that, while most of the low back treatment at issue was causally related to the employee’s work injuries, all treatment of the employee’s neck was unrelated to her work injuries, so he denied all neck-based claims by either the employee or any intervenor.  Accordingly, the judge granted the intervention claim of HealthPartners, for reimbursement of payments made to MAPS, HealthEast, and Glencoe, finding that those payments also related to treatment for the employee’s low back.  The judge granted also the intervention claim of HealthEast itself, for payment for the chronic pain program directed by Dr. Lutz, finding that treatment reasonable and necessary, in reliance on the opinion of Dr. Yellin.  The judge denied, however, the claim of MAPS for Dr. Lutz’s treatment, concluding that MAPS’s charges appeared to duplicate the charges of HealthEast/St. John’s.  Further, the judge determined that the treatment parameters were not applicable, and he denied the employee’s out-of-pocket claims related to pool therapy and to treatment of the neck and other non-compensable conditions, awarding only those claims related to treatment of her low back.  Benefits and reimbursements awarded were ordered paid by Glencoe and by Tino’s and its insurer.  The employee appeals from the compensation judge’s denial of the intervention claim of MAPS.

In reviewing cases on appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.”  Minn. Stat. § 176.421, subd. 1.  Substantial evidence supports the findings if, in the context of the entire record, “they are 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 evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.  Id. at 60, 37 W.C.D. at 240.  Similarly, “[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 Foods Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).  Findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless 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.

At Finding 15, the compensation judge concluded as follows:

Underscoring added.  In a related conclusion at Finding 17, also appealed from by the employee, the judge determined that “[t]he intervention claim of Health Partners is for reimbursement for payments made to MAPS, Health East, and Glencoe Regional Health Services.  The treatment was causally related to the low back and compensable.”  The judge did not comment in his brief memorandum on his denial of MAPS’s claim.  Arguing that the claim by HealthEast/St. John’s is for “facility usage” and that the claim by MAPS is for Dr. Lutz’s services, the employee contends that the judge erred in denying the MAPS claim.  She acknowledges that MAPS’s medical records are identical with HealthEast’s records, but she argues that “for every date of service billed by HealthEast there was a separate bill for the same date of service submitted by MAPS,” that “the bills used different billing codes for the services provided,” and that “there were different charges rendered for the services.”  She argues further that the possibility of duplication of the billings was never an issue before the judge and that the matter should therefore be reversed and remanded to the judge for further consideration and determination.  We agree that substantial evidence does not support the judge’s conclusion that the two claims are duplicative.

From our review of the record, HealthEast/St. John’s filed its Motion to Intervene on March 5, 2009, and we do not find any amendments to that claim.  MAPS was not given notice of its right to intervene until November 2010.  Thereafter, MAPS filed its Motion to Intervene on November 22, 2010.  At that time, and in a subsequent letter to the compensation judge on December 7, 2010, the MAPS representative identified MAPS’s interest as its Spaeth balance of $7,341.00.  According to MAPS’s intervention exhibit filed on November 22, 2010, MAPS’s Spaeth balance was based on treatment and insurance payments covering the period July 20, 2009, through November 8, 2010.  The medical records accompanying MAPS’s motion also relate to that timeframe.  The treatment referenced in the intervention claim of MAPS appears clearly to post-date the treatment referenced in the intervention claim of HealthEast/St. John’s, and therefore it appears impossible for the two claims to be duplicative.

On review, it is not entirely clear what documents the judge was considering when he arrived at his finding, and we acknowledge finding the record also otherwise ambiguous in places.  We presume that the claims of the intervenors are those entered into the imaging system, as even they are not part of the paper record before us; but it is not our obligation to find the facts here on appeal.  We do conclude, however, after comparing the motion to intervene filed by HealthEast/St. John’s on March 5, 2009, with that filed by MAPS on November 22, 2010, that the judge’s finding of duplication of claims appears at least to be unsupported by substantial evidence. 

In light of the judge’s finding that the chronic pain program administered by Dr. Lutz was reasonable and necessary treatment for the employee’s low back work injury, and acknowledging that we are not the ultimate finder of fact, we remand the matter to the compensation judge for reconsideration and new findings, based on the record as limited to documents evident in the division’s electronic imaging system.