The employee appeals the compensation judge’s finding that care and treatment provided to the employee by the Institute for Low Back and Neck Care (ILBNC) from May 22 through September 13, 2012, was not reasonable or necessary to cure or relieve from the effects of the employee’s personal injuries of April 18, 2006, October 14, 2007, and/or May 28, 2008.  Because the compensation judge did not make sufficient, specific findings of fact addressing the issues raised and argued by the parties, we vacate and remand.

Patrice Bennetts, the employee, sustained admitted work injuries to her low back and neck on April 18, 2006, and reinjured her neck on October 14, 2007, and May 28, 2008, while working as a registered nurse for United Hospital, the self-insured employer.

A cervical MRI scan on November 3, 2008, revealed mild facet arthropathy at C3-4 on the left.  There was minimal bulging and spondylolisthesis at C4-5 with moderate left-sided facet arthropathy and mild narrowing of the neural foramen on the left without definite neural impingement.  Annular bulging was noted at C5-6 and C6-7.  Facet arthropathy was also noted at C7-T1, on the left greater than the right.

A lumbar MRI scan on November 25, 2008, revealed mild to moderate thoracolumbar spondylosis with Scheuermann’s-like endplate changes.  There was mild nuclear dehydration, but no annular tears or herniation at L3-4 through T12-11.  At L4-5, there was a broad-based disc herniation closely approximating the L5 nerve root sleeves, on the right greater than on the left.  There was minimal annular bulging at L5-S1, with no central foraminal stenosis, but with chronic bilateral L5 spondylolysis with a trace of spondylolisthesis of L5 on S1.

As of March 3, 2009, the employee’s treating physician released the employee to return to light-duty outpatient work, including patient contact by telephone and computer recordkeeping. The employee has permanent restrictions, including sedentary work with positional changes every 30 minutes; standing, walking, stretching, or resting every hour; no carrying or level-lifting over 20 pounds frequently; may bend and lift up to 5 pounds with back straight with no twisting; and may push or pull up to 20 pounds without bending and up to 50 pounds on wheels.

Between October 2009 and August 2012, the employee underwent multiple lumbar spine facet joint blocks, medial branch blocks, and radio frequency neurotomy (RFN) procedures.  Similarly, multiple cervical spine facet joint blocks, medial branch blocks, and RFNs were performed between December 2008 and July 2012.

Specifically at issue are medial branch blocks and RFN procedures performed in 2012 by physicians at the ILBNC.  On May 22 and June 5, 2012, the employee underwent lumbar spine medial branch blocks from L3 to S1 on the right.  On August 21, 2012, RFNs were performed from L3 to S1 on the right.  On May 24 and June 26, 2012, the employee underwent cervical spine medial branch blocks at three levels from C5 to C7 on the right.  On August 24, 2012, RFNs were performed from C5 to C7 on the right.

On February 28, 2013, the employee filed a Medical Request seeking payment of bills from the ILBNC for the 2012 procedures and related visits.  In a Decision and Order filed May 3, 2013, a compensation judge denied payment for the bills.  The employee then filed a Request for Formal Hearing on May 24, 2013.  Following a hearing on July 10, 2013, a compensation judge at the Office of Administrative Hearings, in a Findings and Order filed August 9, 2013, determined the disputed care and treatment was not reasonable or necessary to cure or relieve from the effects of the employee’s work-related injuries.  The employee has appealed.

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 (2012).  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, 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 evidence or not reasonably supported by the evidence as a whole.”  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).

Two issues were presented at the hearing:  1) Whether the care and treatments provided to the employee by the ILBNC for the period from May 22 through September 13, 2012, were consistent with the Minnesota treatment parameters, specifically, Minn. R. 5221.6020, subp. 2; Minn. R. 5221.6040, subp. 10; Minn. R. 5221.2600, subps. 4, 5.A., and 5.B.; and Minn. R. 5221.6205, subps. 4, 5.A., and 5.B.; and 2) whether the treatment provided between May 22 and September 13, 2012, was reasonable and necessary to cure or relieve from the effects of the employee’s admitted work injuries.^[1]

The compensation judge made only one finding addressing the disputed issues before her, concluding in finding 5 that,

On appeal, the employee argues that various factual findings of the compensation judge are not supported by the record as a whole and are clearly erroneous.  The compensation judge’s findings and order, however, contain no factual findings supporting the compensation judge’s ultimate legal conclusion.

Pursuant to Minn. Stat. § 176.421, subd. 1(3), a party may appeal to the Worker’s Compensation Court of Appeals on the ground that the “findings of fact and order were clearly erroneous and unsupported by substantial evidence in view of the record as a whole.”  The question before this court on appeal is whether the compensation judge’s findings of fact are adequately supported by substantial evidence in the record as a whole.  A compensation judge is required to determine all contested issues of fact presented at the hearing and to include a memorandum “only if necessary to delineate the reasons for the decision or to discuss the credibility of witnesses.”  Minn. Stat. § 176.371.  This court has previously stated that a compensation judge should “state with clarity and completeness the facts essential to the ultimate decision so that a reviewing court can determine from the record whether the facts support the judge’s decision” and “should not leave the reviewing court the obligation to seek or spell out the facts supporting the judge’s decision or choose between conflicting testimony and inferences.” See, e.g., Hart v. EVTAC Mining Co., No. WC05-166 (Oct. 31, 2005); Mendez-Merino v. Farmstead Foods, slip op. at 7-8 n.7 (W.C.C.A. Aug. 7, 2001).

While the compensation judge’s memorandum includes a discussion of the evidence, conclusions expressed in a memorandum are not findings of fact.  In this case, the findings and order contain no essential findings of fact upon which to make a review.

Moreover, the compensation judge’s findings and order do not address the issue - - explicitly raised and argued by the parties - - of whether the disputed treatment was consistent with the specified treatment parameters.

            Minnesota Statutes § 176.135, subd. 1(a), states that an employer is to furnish “any medical, psychological, chiropractic, podiatric, surgical and hospital 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.”  By establishing standards for treatment, the treatment parameter rules “provide the yardstick by which the treatment offered by the health care provider is measured” and aid the trier of fact “in identifying reasonable and appropriate medical treatment.”  Pelowski v. K-MART Corp., 627 N.W.2d 89, 92-93, 61 W.C.D. 276, 279 (Minn. 2001) (citing Jacka v. Coca-Cola Bottling Co., 580 N.W.2d 27, 35, 58 W.C.D. 395, 407 (Minn. 1998)).

At the hearing, the self-insured employer argued that two prior cervical and lumbar RFNs, coupled with the 2012 RFN treatments at issue, exceeded and were inconsistent with the treatment parameters, specifically Minn. R. 5221.6200, subps. 4 and 5, and Minn. R. 5221.6205, subps. 4 and 5.  The employee, on the other hand, argued that the treatment parameters are guidelines and the employee’s condition warrants an exception to the treatment parameters.  See Minn. R. 5221.6050, subp. 8; Jacka, 580 N.W.2d at 35-36, 58 W.C.D. at 408 (“rare case” exception).

In determining the compensability of medical treatment when specific treatment parameters are raised by the parties, a compensation judge must consider whether the treatment parameters apply.  If so, the judge must determine whether the treatment is consistent with the treatment parameter(s) and whether the treatment was medically necessary as defined in part 5221.6040, subp. 10.  Finally, the judge must consider whether a departure from the applicable parameter is or was necessary.  Minn. R. 5221.6050, subp. 7.D.; Jacka, 580 N.W.2d at 34, 58 W.C.D. at 405 (the compensation judge should utilize the rules in determining appropriate treatment).

The compensation judge’s finding that the treatment at issue was not reasonable and necessary lacks essential findings of fact to support the ultimate legal conclusion reached and does not specifically address the determinative issues presented by the parties.  Accordingly, a remand is necessary for consideration of whether the treatment at issue is consistent with the specified treatment parameter rules, i.e., whether the treatment and care at issue was reasonable and necessary under those rules, and, if not, whether a departure is warranted.  Compare, e.g., Roberts v. Supervalue, Inc., slip op. (W.C.C.A. Jan. 9, 2003); Winquist v. Hansen Gravel, Inc., slip op. (W.C.C.A. Dec. 6, 1999); Moorman v. St. Anthony Health Ctr., slip op. (W.C.C.A. Feb. 17, 1999).

We, accordingly, vacate the findings of fact and order, and remand the matter to the compensation judge for redetermination, on the existing record, in accordance with this opinion.