The employer and insurer appeal from the compensation judge’s decision to award payment for certain medical treatment, and they appeal from the compensation judge’s determination that the workers’ compensation treatment parameters do not apply to certain treatments involved, including MRI charges, “because the employer and insurer were denying primary liability” for the December 10, 1997 injury involved herein.  We affirm.

The employee herein, Michael Bayliss, was a long-term employee of National Steel Pellet Company, the employer herein.  The employee worked primarily as a laborer in the employer’s mine.  During his years of working for the employer, the employee sustained a number of different work-related injuries.  He sustained admitted injuries on February 3, 1989, March 7, 1990, April 24, 1992, December 24, 1995, July 17, 1997, July 23, 1997, January 11, 1999, August 29, 2000, February 8, 2001, April 24, 2001, October 2, 2002, and March 23, 2003.  These admitted injuries involved a number of different body parts, including the employee’s low back, mid back, neck, knees, and upper extremities in the nature of carpel tunnel syndrome.  The employee also alleged a Gillette injury culminating on or around December 10, 1997.  This injury involved a number of the same body parts, including the employee’s neck.

In 2006, the parties entered into a stipulation for settlement with regard to all of the admitted and alleged work injuries, which indicated that only reasonable and necessary medical treatment related to the employee’s low back, mid back, neck, knees, and carpal tunnel syndrome would remain open subject to all defenses.

The employee has a complicated medical history.  The records show that on August 28, 2002, the employee saw Dr. Greene at the Hibbing Family Medical Center.  The employee complained of persistent headaches that were usually on the left side of his head.  He also reported some episodes of confusion and occasional pressure behind or above his left eye along with intermittent dizziness.  It was noted that the employee had recently undergone a head CT scan that showed findings consistent with an arachnoid cyst.  This finding was not responsible for the headaches, but the doctor that ordered the scan felt that the employee should be rechecked after a few months.  As such, Dr. Greene ordered another CT scan of the head.

The employee underwent a CT scan of the head at University Medical Center on August 23, 2002.  It again showed a finding consistent with an arachnoid cyst.  The employee also underwent an MRI of the brain at University Medical Center on September 3, 2002.

As of April 2004, the employee was continuing to complain of pain throughout his entire spine as well as in his shoulders, wrists, hands, hips, knees, and ankles.  Dr. Greene was assessing the employee with multiarticular degenerative arthritis, secondary to work trauma.  In May 2004, Dr. Greene placed the employee at maximum medical improvement (MMI).  At the hearing in this matter, the employee stipulated to MMI as of May 11, 2004.

The employee continued to treat with Dr. Greene in 2004 and 2005.  As of June 2005, the employee continued to complain of pain in his neck, thoracolumbar spine, and other major joints, including his hips, shoulders, and knees.  Dr. Greene continued to assess the employee with multiarticular arthritis, especially in the cervical and thoracolumbar spines.  The employee was referred for MRIs of both areas.

On July 30, 2005, the employee underwent a number of MRIs at LifeScan Standup MRI, including an MRI of his cervical spine.  The MRI of the cervical spine showed mild central canal narrowing at C5-6 and C6-7, secondary to broad-based disc bulges.  The employee followed up with Dr. Greene on August 4, 2005, and the doctor noted that the recent MRIs also confirmed his suspicions that the employee had bony degenerative changes in addition to degenerative changes in the discs at multiple levels of the cervical and thoracolumbar spine.  The employee saw Dr. Greene again in March 2006.  He reported that he recently received a settlement from his previous work injuries and had also retained benefits allowing continued treatment for his various problems.  The employee’s current assessment included chronic spinal pain and multi-articular pains in the right knee that were worse at the time.

On December 1, 2006, the employee saw Dr. Cardwell at Hibbing Family Medical Clinic.  At that time, the employee was complaining of a headache on the left side of his head.  The employee also complained of a throbbing headache starting at the base of his neck and working up the left side of the head.  The employee was once again sent for an MRI of the cervical spine and head to rule out any type of aneurysm problems.  If negative, it was felt that the employee would probably need to perform therapy for muscle tension headaches.

On December 6, 2006, the employee underwent a brain MRA at Fairview Medical Center.  The indication for the scan was “pain, throbbing and [history] of arachnoid cyst.”  The December 2006 scan was normal.  When the employee saw Dr. Cardwell again on December 14, 2006, he was still complaining of a headache on the left side of his head.  He was also complaining of occasional blurred vision in the left eye.  There were no other neurological symptoms.  The doctor commented that the employee’s MRA had been absolutely normal.  He informed the employee that he did not believe there was anything going on centrally, and the doctor thought that the employee most likely had muscle tension problems.

The employee saw Dr. Cardwell again on May 7, 2007.  He was complaining of neck pain.  He also stated that he occasionally had headaches and some muscle tension pain.

At the hearing of this matter, the employee testified that between 2003 and 2009, he experienced tight muscles across his shoulders, knots and spasms in his mid-back, and “sometimes slight headaches up the sides” of his head.

In July 2009, the employee saw Dr. Cardwell again.  The employee was reporting a flare up in his symptoms, including muscle pain and spasm down the lower neck.

The employee was once again seen by Dr. Cardwell on September 2, 2009.  He was complaining primarily of neck pain.  He was reporting a flare up in neck pain over the last several months that was not getting better.  The employee was, reportedly, exquisitely tender at the left occipital triangle and in some of the paraspinous muscles.  The employee was assessed with neck pain that was felt to be most likely musculoskeletal in nature.  The employee was referred for physical therapy and prescribed Ultram.  Dr. Cardwell also recommended an MRI of the cervical spine.

The employee underwent an MRI of the cervical spine at Virginia Regional Medical Center on September 25, 2009.  This showed bulging discs at C5-6 and C6-7, which produced moderate front and back central canal stenosis without neural compromise.  The report also indicated that the employee had moderately stenotic left intervertebral canals at both levels, on the basis of uncinate spurs.

The employee continued treating with Dr. Cardwell.  As of March 24, 2010, the employee reported doing well with physical therapy.  He felt that his pain had gotten better to the point where he thought he could return to work.  However, when seen again by Dr. Cardwell on May 4, 2010, the employee reported that he was having headaches.  The doctor noted that at one time, the employee had a clear fluid drain from his nose.  The doctor believed that the employee was found to have a subarachnoid cyst, and the employee was notably concerned about that.  As such, Dr. Cardwell recommended an MRI of the head and neck.

The employee underwent an MRI of the brain on May 12, 2010 at Virginia Regional Medical Center.  The scan was felt to be essentially within normal limits.  The scan, however, reportedly suggested a posterior fossa arachnoid cyst.  The employee also underwent an MRI of the cervical spine on May 12, 2010.  It showed relatively prominent bulging disc material at C5-6.  A bulging disc was also noted at C6-7.

On March 3, 2011, the employee was seen for an independent medical examination by Dr. Paul Cederberg, at the request of the employer and insurer.  Dr. Cederberg reviewed updated medical records and examined the employee.  Dr. Cederberg diagnosed the employee with multi-level degenerative disc disease of the cervical, thoracic, and lumbar spines, along with muscle tension headaches, and probably mild joint AC arthritis in the shoulders.  Dr. Cederberg did not believe that the December 10, 1997 Gillette injury could be considered a substantial contributing cause to the employee’s condition.  Regardless of cause, Dr. Cederberg did not believe that cervical and brain MRI scans, which had been conducted in May 2010, were reasonable and necessary treatment as the employee had no neurological defects that would have warranted the MRIs.  Dr. Cederberg felt the employee needed no additional medical treatment.

The employee’s treating physician, Dr. Cardwell, wrote a report to the employee’s attorney dated August 21, 2011.  Dr. Cardwell indicated that the brain and cervical MRIs done in May 2010 were done to “evaluate his neck problems and arm numbness.”  The doctor had ordered an MRI of the brain because of “recurrent headaches as well as complaining of clear leakage coming from his sinuses.”  An MRI had been ordered because a previous CT scan of the brain did show an irregularity and possible mass, but not where it was located.  Dr. Cardwell wrote that the MRI of the brain in 2010 was ordered “to rule out any other etiology of the chronic headaches and his other symptoms.”  The doctor felt that these scans were necessary to “come up with a diagnosis accurately as well as to rule out other potentially serious causes for Mr. Bayliss’s symptoms.”

The case came on for hearing before Compensation Judge Nancy Olson on September 17, 2012.  The compensation judge was asked to determine whether the employer and insurer were required to pay for the following medical treatment:  the May 12, 2010 cervical and brain MRI scans, massage therapy with Mystic Moon Massage, Skelaxin, Tramadol, and Naproxen prescriptions, and mileage associated with the above treatment.  The following issues were also raised for determination by the compensation judge:

The compensation judge “found the employee credible and accepted his testimony that his work on the large machine in the mines caused ongoing shaking and trauma to his neck area.”  As such, the compensation judge’s finding that employee sustained a “Gillette type repetitive micro trauma injury to the neck on or about December 10, 1997, which aggravated the employee’s pre-existing degenerative neck problems.”  The compensation judge accepted the employee’s treating physician’s opinion on that point, and December 10, 1997 was used for the Gillette date because it was a date associated with the employee moving from heavier shovel operator work to lighter laborer work.

The compensation judge also found that at the time of the Gillette injury, the employee was continuing to suffer from the effects of a July 17, 1997, injury to his neck and mid back.  The compensation judge indicated that she considered both the July 17, 1997, injury and the December 10, 1997, Gillette injury to be permanent injuries, both of which contributed to the employee’s subsequent neck treatment.

In addition, the compensation judge determined that the employee sustained neck injuries on January 11, 1999, and April 24, 2001.  The compensation judge also determined that the employee sustained a Gillette injury culminating on October 2, 2002.  Even though the employee had been working lighter duty since December 10, 1997, he was still doing heavy, difficult work that the compensation judge believed would have contributed to the employee’s continued deterioration of his neck condition.

The compensation judge found the opinions of the employee’s treating physicians, Dr. Person, Dr. Greene, and Dr. Cardwell to be persuasive.  She found, based on those opinions, “that the employee’s neck treatment at issue herein was a continuing product of the July 17, 1997, injury, the December 10, 1997, Gillette injury and the October 2, 2002, Gillette injury.”  The compensation judge then indicated that she “would apportion liability between these injuries on a one third for each injury basis.”  The compensation judge “rejected Dr. Cederberg’s most recent opinion that the employee’s neck condition was not work related.”

The compensation judge also specifically accepted Dr. Cardwell’s opinion “that the MRI scans of the brain and neck were reasonable diagnostic tests necessary to determine if the employee’s headaches were a continuing product of the neck injuries and to determine additional treatment for the neck condition.”

The compensation judge also determined that the treatment parameters do not apply to the MRI charges in question “because the employer and insurer were denying primary liability for the December 10, 1997, injury.”  In the alternative, the compensation judge indicated that if the treatment parameters had applied, the compensation judge believed that Minn. R. 5221.6020, subp. 1.(d)(4) and (5) would allow an exception in this case because the employee was experiencing increased symptoms that raised questions of a new cause for his complaints.

The compensation judge found the employee’s testimony and the medical records persuasive as to the medications in question, Skelaxin, Tramadol, and Naproxen, and she found those prescriptions were reasonable and necessary to cure and relieve the employee’s neck pain related to his work injuries.  The compensation judge did, however, deny the requested payments for treatment at Mystic Moon Massage.

In her memorandum of law, the compensation judge stated that she “accepted the employee’s testimony as persuasive and found the employee’s medical records and physician opinion more persuasive than the opinion of Dr. Cederberg.”  The compensation judge also indicated that she “believed the employee’s ongoing neck complaints were due to his numerous work injuries primarily the July 17, 1997, incident, the December 10, 1997, Gillette injury and the October 2, 2002 Gillette injury.”

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.

The employer and insurer argue that there is not substantial evidence to support the compensation judge’s finding that the medical treatment in question, the May 2010 scans of the cervical spine and brain, the prescription expenses, and the associated mileage, was reasonable and necessary treatment for the employee’s injuries.

Minn. Stat. 176.135, subd. 1.(a) provides that “The employer shall furnish any medical . . . treatment . . . as may reasonably be required at the time of the injury and any time thereafter to cure and relieve from the effects of the injury.”  The reasonableness and necessity of medical treatment under Minn. Stat. § 176.135 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).  Here, the compensation judge determined that “the MRI scans of the brain and neck were reasonable diagnostic tests necessary to determine if the employee’s headaches were a continuing product of the neck injuries and to determine additional treatment for the neck condition.”  Diagnostic treatment or evaluation to rule out alternative diagnoses for an employee’s symptoms may be compensable, even if it is later determined that the ultimate diagnosis is not work related, where the ongoing symptoms in the same area of the body could otherwise be causally related to the work injury. Bracewell v. St. John’s Hosp., slip op. (W.C.C.A. Oct. 15, 1997); Braatz v. Total Constr. & Equip., slip op. (W.C.C.A. May 19, 1992); Klaven v. Northwest Medical Ctr., slip op. (W.C.C.A. Sept. 24, 1991).  Payment for medical treatment can include the costs of diagnostic testing performed to eliminate possible causes of an employee’s continued symptoms.  Neeb v. Collins Elec. Co., slip op. (W.C.C.A. 1993) (citing Braatz, slip op. and Klaven, slip op.).  To be awarded, medical expenses must be causally related to an employee’s work-related injuries.  See Lang v. H & W Motor Express, 42 W.C.D. 402, 404 (W.C.C.A. 1989), summarily aff’d (Minn. Oct. 27, 1989).  Questions of medical causation fall within the province of the compensation judge.  Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994).

The employer and insurer argue that the employee underwent numerous cervical scans before May 2010, including the scan in 2009.  They argue that there was “nothing that occurred in 2010 as far as his headaches and neurological examination that warranted the taking of a new scan.”  In fact, the employer and insurer contend that scan in 2010 was not related to the employee’s injuries, and they argue that the 2010 scans were only conducted “because of the employee’s and Dr. Cardwell’s concern that the employee’s headaches had something to do with the previously diagnosed brain cyst, especially given the employee’s statement that he was experiencing clear fluid leaking from his sinuses.”

The compensation judge based her decision on the employee’s testimony, which she found persuasive with regard to his ongoing symptoms.^[1]  She also based her decision on the medical records and opinions of employee’s physicians, which she specifically found to be more persuasive than those of Dr. Cederberg.^[2]

The employer and insurer do not question the foundation for Dr. Cardwell’s opinions, nor do they argue that he assumed facts that were not in evidence.  Rather, they argue that the “true reason for the employee being sent for an MRI of the brain in May 2010 was because of the employee’s and Dr. Cardwell’s concern that the employee’s headaches had something to do with the previously diagnosed brain cyst,” and that there was “nothing new” in 2010 with regard to the employee’s neck symptoms or headaches that would warrant the employee’s additional scans.

In his August 2011 report, Dr. Cardwell indicated that the employee had ongoing neck pain and symptoms leading up to the scans in question.  Dr. Cardwell noted that the employee had “neck pain and arm numbness.”  He also noted the employee’s “recurrent headaches.”  Dr. Cardwell did acknowledge that the employee had clear leakage coming from his sinuses and that the employee had a brain mass.  However, Dr. Cardwell explained his opinion that “the medical treatment that has been rendered to Mr. Bayliss at this time was medically necessary for alleviation of Mr. Bayliss’ symptoms and to evaluate and diagnos[e] the cause of Mr. Bayliss’ symptoms.”  Dr. Cardwell opined that the treatment had been “reasonable and necessary and needed to be done to rule out any other etiologies to Mr. Bayliss’s symptoms.”  Therefore, Dr. Cardwell’s opinion provided substantial evidence for the compensation judge’s determination that the scans in question were reasonable diagnostics.

The employer and insurer do question the employee’s credibility.  The employee admitted to having prior headaches, but he also testified that his 2010 symptoms were “pain like I’ve never felt before in my head so - - I mean I’ve had headaches before but this wasn’t just a headache,” and he said this was “completely different” from anything he had before.  The employer and insurer argue that, based on his medical records, the employee’s headaches in 2010 were no different from those he had in 2002 and 2006.  We acknowledge that the employee admitted at the hearing to having a “terrible” memory, and there were times when he had difficulty remembering certain symptoms or treatment, but the compensation judge was certainly aware of those facts in reaching her decision.^[3]  She also made it clear that she found the scans to be reasonable diagnostics given the remainder of the evidence presented as well.

The compensation judge determined that the 2010 “scans of the brain and neck were reasonable diagnostic tests necessary to determine if the employee’s headaches were a continuing product of the neck injuries and to determine additional treatment for the neck condition.”  Dr. Cardwell’s opinions, along with the employee’s testimony regarding his present condition, provided substantial evidence to support the compensation judge’s determination that the treatment at issue was reasonable and necessary, and we affirm.^[4]

The compensation judge found that the medical treatment in question was reasonable, necessary, and causally related to the denied December 1997 Gillette injury and to the admitted July 1997 and October 2002 injuries as well.  The employer and insurer argue that “to rule that the employer and insurer did not have a defense in the treatment parameters due to a denial of primary liability for one out of twelve separate injuries when all of the other eleven have been admitted is simply untenable.”  In other words, the employer and insurer argue that because “the compensation judge found that the medical treatment being sought by the employee was causally related to some of his admitted injuries, the employer and insurer must be allowed to assert the treatment parameters as a defense.”

The treatment parameters “do not apply to treatment of an injury after an insurer has denied liability for the injury.”  Minn. R. 5221.6020, subp. 2.  This denial “includes both a primary liability denial as well as denial of medical causation.”  See, e.g., Schulenburg v. Corn Plus, 65 W.C.D. 237, 248-49 (W.C.C.A. 2005) (citing Oldenburg v. Phillips & Temro Corp., 60 W.C.D. 8 (W.C.C.A. 1999), summarily aff’d (Minn. Feb. 15, 2000); Mattson v. Northwest Airlines, slip op. (W.C.C.A. Nov. 29, 1999)).  “[W]hen an employer and insurer deny liability for a work injury . . . [they] have no real interest in information about the course of the employee’s care and no legitimate expectation of influencing or limiting the employee’s treatment options.  The same may be said where the employer and insurer are denying that an ‘admitted’ injury has any continuing effects.”  Mattson, slip op. (quoting Oldenburg, 60 W.C.D. at 13).  An employer and insurer “cannot deny the employee’s condition is work-related, yet assert the protection of, or demand compliance with, medical treatment parameters that apply only to work injuries.”  Mattson, slip op.; see also Paoli v. Rainbow Foods, slip op. (W.C.C.A. July 28, 2006).

In this case, the compensation judge was asked to determine whether the treatment at issue was related, in part, to the 1997 Gillette injury, for which primary liability had been denied.  Thus, under the plain language of Minn. R. 5221.6020, subp. 2, the treatment parameters do not apply.

The employer and insurer cite this court’s decision in Hausladen v. Egan Mech., No. WC08-136 (W.C.C.A. July 7, 2008) to support their argument that although the compensation judge found that the medical treatment in question was reasonable, necessary, and causally related to the denied December 1997 Gillette injury, said treatment was also related to the admitted July 1997 and October 2002 injuries.  Therefore, they essentially argue that the treatment parameters should apply to the overall case.  We are not persuaded.

In Hausladen, the independent medical examiner concluded that the employee’s condition was not related to the work injury involved.  As this court explained, however, the only indication that the employer and insurer could have been denying causation was a single statement on the first page of the medical response, and the employer and insurer went on to clarify, later in the medical response, that they were denying the treatment at issue because they felt that the employee had not been compliant with her treatment recommendations.  Otherwise, the employer did not raise causation as a defense, and it relied solely on the treatment parameters in defense against the employee’s claim for medical treatment.  On review, this court noted the seemingly conflicting information on the medical response but concluded that the employer and insurer’s actions could not be viewed as a denial of causation.  As such, this court affirmed the compensation judge’s decision, stating that “Substantial evidence therefore supports the judge’s conclusion that the treatment parameters are applicable.”  Id.

Here, by contrast, the employer and insurer have maintained a causation defense to the treatment at issue, in the form of the primary liability denial of the Gillette injury.  The compensation judge was asked to consider whether subsequent treatment was related to any or all of the employee’s prior injuries.  While the compensation judge found that the treatment was related to the admitted July 1997 and October 2002 injuries, she found that it was related to the 1997 Gillette injury as well.^[5]

Furthermore, as indicated above, the employer and insurer argue that the employee’s headaches were related to his brain cyst and not his neck injuries.  Therefore, although they have admitted primary liability for the July 1997 and October 2002 injuries, the employer and insurer are, at least implicitly, denying medical causation by arguing that the 2010 scans are not related to an underlying condition and not to any of the injuries involved herein.

Ultimately, the employer and insurer are asking that we allow them to deny primary liability for the Gillette injury but then apply the treatment parameters to treatment that is subsequently found to be related, at least in part, to that injury because they have admitted primary liability for other injuries that are involved as well.  However, the plain language of Minn. R. 5221.6020, subp. 2, and the case law make it clear that where there is a denial of primary liability, the treatment parameters do not apply.  Therefore, we affirm the compensation judge’s determination that the treatment parameters do not apply in this case.