The employer and insurer appeal the compensation judge’s approval of payment for chiropractic treatment and massage therapy under a departure from the treatment parameters.  We affirm.

On October 20, 2009, Marietta Ounasser, the employee, sustained a right shoulder and neck injury when she slipped and fell in a bathroom while working as an aide at Golden Living Center Rochester West, the employer, which was insured for workers’ compensation liability by Insurance Company of Pennsylvania, administered by Constitution State Services Company.  The employee hit her head on a sink and landed on the floor.  The employee was treated that day at the emergency department at the Mayo Clinic for neck pain, right shoulder pain, and right hip pain.  X-rays of the right hip, right clavicle, and cervical spine were negative.  A head CT scan was negative, and a cervical spine CT indicated pre-existing degenerative disc disease.  The employee was diagnosed with a cervical strain and prescribed a cervical collar.  The next day, the employee was taken off work until October 27, 2009.  The employer and insurer admitted liability for the injury.

On November 6, 2009, the employee was evaluated by Dr. Mioki Myszkowski, a spine specialist at the Mayo Clinic.  Dr. Myszkowski recommended that the employee continue wearing the cervical collar and be limited to light-duty work.  Dr. Keith Bengston at the Mayo Clinic also restricted the employee to light-duty work and recommended right-sided cervical facet injections at C5-6 and C6-7.  The insurer refused to approve this treatment.

The employee underwent 13 sessions of physical therapy from December 2009 through February 2010, which is approximately an eight week period.  On February 22, 2010, the employee was again examined by Dr. Myszkowski, who recommended four more weeks of physical therapy.  Dr. Myszkowski again recommended additional physical therapy in March 2010.  The insurer did not approve this treatment.  The employee’s employment with Golden Living Center was terminated in March 2010.  The denial of treatment and the employment termination did not prevent the employee from continuing treatment.  The employee was treated with a facet injection in later March, but Dr. Myszkowski recommended a repeat corticosteroid injection, which was also not approved by the insurer.

In April 2010, the employee filed a medical request for approval of right shoulder injections and physical therapy as recommended by Dr. Myszkowski.  On April 26, 2010, the employee underwent an independent medical examination with Dr. Mark Friedland, who diagnosed chronic multi-level cervical disc disease and objectively resolved cervical sprain/strain.  He also opined that the employee had sustained a temporary injury to her neck on October 20, 2009, had reached maximum medical improvement, and could work without restrictions.  The employer and insurer denied the employee’s medical request as not reasonable, necessary, or causally related to the work injury.  A hearing was held on this issue on September 24, 2010.  A compensation judge found that the employee had not healed from her work injury and was entitled to treatment provided through the date of the hearing as well as ongoing treatment, and that the treatment was causally related to the work injury.^[1]  The employer and insurer appealed.^[2]  This court vacated the judge’s finding regarding ongoing medical care and affirmed the remainder of the judge’s decision.^[3]

The employee continued to experience neck pain and was treated with medication, but she was able to work as a home health aide.  On January 31, 2012, the employee was examined by Dr. Bengston, who recommended chiropractic treatment, massage therapy, and acupuncture.  On March 28, 2012, the employee filed a medical request for the treatment recommended by Dr. Bengston.  The employee did not request a departure from the treatment parameters in the medical request.  The employer and insurer denied the request in a medical response filed May 1, 2012, claiming that the treatment was not reasonable and necessary and was contrary to the treatment parameters.  Specifically, the employer and insurer claimed the employee suffered from chronic pain syndrome and that passive care was not appropriate for treatment of chronic pain under Minn. R. 5221.6205, subp. 3.B.(1)(f).

On May 10, 2012, the employee was examined by Dr. Robert Gustafson, a chiropractor, who recommended conservative treatment with heat, stretching, and massage.  The employee underwent this treatment in 21 sessions from May through September 2012.  The employee experienced temporary relief from her neck pain after the treatments.  After a follow-up appointment on September 26, 2012, Dr. Bengston recommended additional facet joint injections.  Bilateral cervical facet injections at C2-3 and C3-4 resulted in increased pain.  A physical therapy session on October 31, 2012, did not improve the employee’s symptoms.

A request for formal hearing was filed by the employer and insurer, and the hearing addressing the employee’s medical request for payment for the chiropractic treatment was held before a compensation judge on January 11, 2013.  The compensation judge found:  1) the employee’s work injury was a substantial contributing factor to the employee’s ongoing neck symptoms; 2) the chiropractic treatment was reasonable and necessary medical treatment; 3) the treatment reduced the employee’s subjective reports of pain and improved her functionality in activities of daily living; and 4) the employee had met the standard for a departure from the treatment parameters.  The employer and insurer 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.^[4]  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.^[5]  Fact findings are clearly erroneous if the reviewing court, looking at the entire evidence, is left with a definite and firm conviction that a mistake has been committed.^[6]  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.”^[7]

The employer and insurer appeal from the compensation judge’s determination that the chiropractic treatment, massage therapy and acupuncture were reasonable and necessary to cure and relieve the employee from the effects of the work injury.  The employer and insurer further contend that the judge committed an error of law in failing to apply the appropriate treatment parameters and in finding that the employee’s medical treatment qualifies for a departure from the treatment parameters.  We affirm.

The threshold issue before the compensation judge at hearing was whether the chiropractic care and treatment was reasonable and necessary.^[8]  Reasonableness and necessity of medical treatment is a question of fact for the compensation judge, and we review this issue on appeal under the substantial evidence rule.^[9]  In Fuller v. Naegele/Shivers Trading,^[10] the court identified a list of factors the judge should consider when analyzing the reasonableness of chiropractic treatment.^[11]  The compensation judge considered these factors in his analysis of the case.

The compensation judge was persuaded by the evidence from separate medical providers as well as the employee’s testimony in reaching the ultimate determination on reasonable and necessary medical treatment.  The judge relied on the medical opinions from Dr. Bengston, Dr. Myszkowski and Dr. Gustafson to determine that the employee’s ongoing neck symptoms arose out of her work injury.  By contrast, the employer and insurer submitted the medical opinion from the independent medical examiner, Dr. Friedland.  The judge specifically rejected Dr. Friedland’s medical opinion that the recommendation for chiropractic care was random and contraindicated given the employee’s poor result from physical therapy.^[12]  The choice between conflicting medical opinions is a decision for the fact finder.^[13]  In the end, the compensation judge accepted the medical opinions of Drs. Bengston, Myszkowski and Gustafson over the medical opinion of Dr. Friedland.  The judge further accepted as credible testimony the employee’s statements on her pain reduction and increased functionality with chiropractic treatment.  The oral evidence added substantial evidentiary support to the treating doctors’ opinions on measurable results which were compared to the employee’s treatment plan at Southwest Chiropractic Clinic.  We find substantial evidence in the record to support the compensation judge’s finding that the disputed chiropractic care and therapeutic massage were necessary and reasonable to cure and relieve the employee from the effects of the work injury.

The employer and insurer’s arguments at hearing were, first, that the disputed treatment was not reasonable or necessary, and second, that the employee suffered from chronic pain syndrome, a condition for which the treatment parameters prohibit passive treatment.^[14]  They argue on appeal that the judge improperly expanded the issues to include a departure from the treatment parameters since a departure was not raised by the employee at the medical conference nor at the hearing, and also that the judge did not apply the correct parameters for chronic pain conditions.  The employer and insurer seek a reversal of the compensation judge’s decision, asking this court to correct the compensation judge’s failure to review the treatment under the rule for chronic pain conditions and to determine that the judge lacked jurisdiction to consider the issue of whether the employee qualifies for a departure from the treatment parameters.  We are not persuaded by the employer and insurer’s arguments.

First, we note that the employee’s diagnosis was not listed as including a chronic pain condition until October 2012, which was after the treatment at issue was provided.  Second, the compensation judge gave a brief description on the record of the issues presented, indicating that the issues included whether the disputed treatment “is reasonable and necessary and falls within the Treatment Parameters or a departure therefrom.”^[15]  No party corrected or repudiated that statement.  Moreover, all parties were aware of the fact that the employee had undergone previous physical therapy; any of the additional treatment in dispute would require a departure from the treatment parameters.  The issue of a departure from the parameters was clearly stated on the record and fairly included at hearing.  The judge did not err by addressing and awarding the treatment on that basis.

Finally, the employer and insurer argue the judge made an error of law based on a strict reading of the language contained in subdivision 8 of Minn. R. 5221.6050.  Under that rule, for additional treatment to be compensable, “[a] health care provider must provide prior notification of the departure."^[16]  “Prior notification is the responsibility of the health care provider who wants to provide the treatment” listed in that subpart, including “treatment that departs from a parameter limiting the duration or type of treatment . . . .”^[17]  Failure to follow the notification requirements may render the provided treatment not compensable.^[18]  However, there is no indication that the employer and insurer raised the notification requirement of the parameters at the hearing before the compensation judge.  A hearing shall be limited to the issues raised by the notice or petition unless all parties agree to expand the issues, and it is generally inappropriate for a compensation judge to decide a contested issue on grounds not raised or litigated by the parties.^[19]  In this case, we decline to consider issues raised for the first time on appeal.^[20]  Therefore, we will not address the notification issue.