The employee appeals the compensation judge’s findings that that the employee did not have restrictions related to his work injuries from and after May 23, 2013, and that his July 17, 2013, medical treatment was not related to either of his work injuries, as well as the compensation judge’s denial of his claim for temporary total disability benefits based on her findings that the employee did not cooperate with rehabilitation assistance, had withdrawn from the labor market, and did not conduct a reasonable and diligent job search.  We affirm in part and reverse in part.

On September 3, 2011, Juan Rivera, the employee, sustained an umbilical hernia injury while working in the sanitation department at Cargill Kitchen Solutions, Inc., the employer.  The employer was insured for workers’ compensation liability by New Hampshire Insurance Company, administered by Sedgwick Claims Management.

The employee first treated for abdominal pain in October 2011 with Dr. Robert Mullaney, who diagnosed an umbilical hernia and referred the employee to Dr. Matthew Kissner.  Dr. Mullaney noted that emergency surgery was not necessary since the employee did not have obstructive symptoms.  The employee did not lose any time from work due to his hernia injury.  The employee was evaluated by Dr. Kissner on November 2, 2011.  Dr. Kissner recommended hernia repair surgery and noted that the employee needed to get his diabetes under control to avoid recurrence or any complications.  On January 20, 2012, the employee underwent a pre-operative physical with Dr. Mullaney for the hernia surgery.  Dr. Mullaney did not clear the employee for surgery because of his poorly controlled diabetic condition.

On November 12, 2012, the employee sustained a left shoulder injury and was assigned restrictions of no lifting over 30 pounds and no overhead work.  The employer and insurer initially admitted liability for this injury.  In December 2012, the employee began working with a qualified rehabilitation consultant (QRC) intern for disability case management services.  The employee was terminated from his employment on May 22, 2013.  The QRC conducted a rehabilitation consultation on May 29, 2013, and the parties agreed to the provision of rehabilitation services.  On June 4, 2013, the QRC indicated that job search would begin shortly.

The employee filed a claim petition on June 10, 2013, for temporary total disability benefits and rehabilitation benefits based on his left shoulder and his hernia injuries.  The employee met with the QRC and a job placement specialist and signed a job placement plan and agreement dated June 18, 2013, which required the employee to conduct a full-time job search, submit two to three job applications a day, and maintain a daily log to be forwarded weekly.  The employee followed up on some job leads from the placement specialist but, due to transportation costs and inability to pay, did not follow up on all leads.

The employer and insurer filed a rehabilitation request for termination of rehabilitation services on August 6, 2013, based on a denial of primary liability.  The employee did not submit any job logs until August 16.  The employee testified that he looked for some work on his own.  He was offered a job at a greenhouse but turned it down because he was attending school to obtain a commercial driver’s license with assistance from the WorkForce Center.  On September 10, 2013, the QRC filed a rehabilitation plan amendment placing the employee’s file on hold given the dispute regarding the provision of rehabilitation services.  The record does not indicate the date that the employee began attending the driving school, but apparently this was after the file was placed on hold since there is no discussion of retraining in the QRC’s file.

The employee was evaluated by Dr. Anne-Marie Lee, an endocrinologist, on June 14, 2013.  Dr. Lee completed an assessment of the employee’s multiple conditions, including diabetes, hyperlipidemia, left shoulder impingement syndrome, hernia, hypertension, and an eye condition.  The employee returned to Dr. Mullaney on July 3, 2013.  The stated reason for the visit was to “[r]echeck hernia, would like referral to surgeon but would like diabetes more under control.”  (Ex. I.)  Dr. Mullaney’s progress note of that date indicates, “[h]ere today with umbilical abdomen pain that is chronic in nature but getting worse over the last 5 days.  He did vomit once 3 days ago and is not vomiting since . . . .  He has diabetes which is very poorly controlled and he has been seen by endocrinology.  We discuss[ed] starting insulin and he is agreeable to that.”  (Ex. I.)

As recommended by Dr. Mullaney, the employee followed up with Dr. Lee regarding the status of his diabetes on July 17, 2013.  Later that day, the employee visited with Dr. Mullaney about his diabetes and described abdominal pain related to his hernia condition.

On October 22, 2013, the employee was evaluated by Dr. Matthew Melin at the request of the employer and insurer.  Dr. Melin opined that the employee’s umbilical hernia injury was work-related, treatment to date was reasonable and necessary, and the proposed hernia surgery was reasonable and necessary.  He also stated that the hernia had not resulted in disability and the employee had no lifting restrictions related to the hernia.

A hearing was held on February 27 and March 4, 2014, on the employee’s claim petition and the employer and insurer’s request to terminate rehabilitation.  Issues at the hearing included primary liability for both injuries, notice for the hernia injury, rehabilitation services, left shoulder surgery approval, and temporary total disability benefits, intervention interests, and attorney fees.  The compensation judge found that the employee’s injuries were work-related and that most treatment was reasonable and necessary, including the left shoulder surgery.

The employee appeals the compensation judge’s findings that that the employee did not have restrictions related to his hernia injury from and after May 23, 2013, that the July 17, 2013, medical treatment related to control his diabetes was not related to his work injury, and that the employee was not entitled to temporary total disability benefits from and after May 23, 2013, based on findings that the employee did not cooperate with rehabilitation assistance, did not conduct a reasonable and diligent job search, and had withdrawn from the labor market.

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, 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).

Moreover, a decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which the Workers’ Compensation Court of Appeals may consider de novo.  Krovchuk v. Koch Oil Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993), summarily aff’d (Minn. June 3, 1993).

The employee argues that substantial evidence does not support the compensation judge’s finding that he did not have restrictions related to his hernia injury from May 23, 2013, through the date of the hearing.  The employee’s hernia was diagnosed in October 2011.  The employee continued to work for the employer without any restrictions until his employment was terminated on May 22, 2013.  He did not lose any time from work due to the hernia injury.  The employee testified that he continued to work because he needed to work.  Dr. Melin opined that the employee had no disability or restrictions related to lifting due to his hernia.  The employee points to treating physician Dr. Mullaney’s note from July 17, 2013, where he wrote that the employee was unable to work until the hernia was repaired.

The compensation judge specifically found that this opinion was not persuasive “in light of the employee’s ability to work for the employer through May 22, 2013, without any restrictions and his self-assessment at hearing indicating he had no restrictions related to the hernia.”  (Finding 14.)  Substantial evidence supports the compensation judge’s finding that the employee did not have restrictions related to the hernia injury from May 23, 2013, through the date of the hearing.

The employee appeals from the compensation judge’s denial of payment for the employee’s treatment at Allina Medical Clinic on July 17, 2013.  The employer is obligated to provide the injured worker with medical care which may “reasonably be required” to cure and relieve from the effects of the injury.  Minn. Stat. § 176.135, subd. 1(a).  The employee has the burden of proof in disputes over the reasonableness of treatment.  Adkins v. Univ. Health Care Ctr., 405 N.W.2d 231, 233, 39 W.C.D. 898, 900 (Minn. 1987).  The question of reasonableness is one of fact for the compensation judge.  Jones v. Wal Mart Stores, Inc., slip op. (W.C.C.A. Sept. 9, 2002).

In this case, the employee was evaluated by Dr. Lee, an endocrinologist, on June 14, 2013, for assessment of multiple conditions.  The employee returned to Dr. Mullaney on July 3, 2013.  The summary visit note under “Diagnoses” indicates “inguinal hernia - primary and diabetes mellitus type II, uncontrolled,” and the reason for the visit was to recheck hernia for surgery referral “but would like diabetes more under control.”  (Ex. I.)  Dr. Mullaney’s progress note of that date indicates the employee was there with chronic umbilical abdomen pain that was worsening and that his diabetes was very poorly controlled.  The doctor also noted that the employee had been seen by endocrinology and that the employee was agreeable to starting insulin.  (Ex. I.)

The employee was seen again by Dr. Lee at Dr. Mullaney’s request on July 17, 2013.  In Dr. Lee’s note addressed to Dr. Mullaney, she indicated that the employee had lost three to four pounds and had been adhering to a strict diet and increasing exercise.  Dr. Lee concluded that his diabetes was still uncontrolled but improving.  In the employee’s later visit the same day with Dr. Mullaney, the doctor reiterated his recommendation that the employee commence the use of insulin as previously agreed, but the employee responded that the insulin was too expensive and that he had not worked since May 22, 2013.  Dr. Mullaney noted that the employee’s hernia was stable, that surgery was required, and that the employee would not be able to work until the hernia was repaired.

The compensation judge found that the employee’s treatment at Allina Medical Clinic on July 17, 2013, was not causally related to the employee’s hernia injury since Dr. Lee’s appointment involved treatment for the employee’s diabetic condition.  Specifically, the compensation judge found that the

We agree with the employee’s argument that the treatment of the employee’s diabetes was reasonably required to effectuate the recommended hernia surgery.  While the employee was being treated for his hernia condition, Dr. Kissner recommended hernia repair surgery and noted that the employee needed to get his diabetes under control to avoid recurrence or any complications.  On January 20, 2012, Dr. Mullaney did not clear the employee for surgery after a pre-operative physical because his diabetic condition was poorly controlled.  Dr. Lee reached the same conclusion after her visits with the employee on July 3 and 17, 2013.

After years of conservative treatment with some improvement in controlling the employee’s diabetes, Dr. Mullaney reiterated his recommendation on July 17, 2013 that the employee start using insulin.  The employee was willing to start insulin use but could not afford it.  While the employee’s diabetic condition may not be causally related to his work injury, treatment for that condition is reasonably required in order for the employee’s work injury to be surgically treated as recommended.  The compensation judge’s decision is not reasonably supported by the evidence as a whole and we reverse the compensation judge’s denial of payment for the employee’s Allina medical treatment on July 17, 2013.

The employee also appeals the compensation judge’s denial of temporary total disability benefits from and after May 23, 2013, based on findings that the employee did not cooperate with rehabilitation assistance, did not conduct a reasonable and diligent job search, and had withdrawn from the labor market.

Receipt of temporary total disability benefits is dependent on a diligent job search.  Redgate v. Sroga’s Standard Serv., 421 N.W.2d 729, 40 W.C.D. 948 (Minn. 1988).  Whether a job search is reasonably diligent depends on the facts and circumstances of the case.  Kunferman v. Ford Motor Co., 56 W.C.D. 163 (W.C.C.A. 1996), summarily aff’d (Minn. Feb. 10, 1997).  “Whether an injured employee makes a reasonably diligent search for suitable employment is a question of fact which must be upheld unless manifestly contrary to the evidence.”  Hanmer v. Wes Barrette Masonry, 403 N.W.2d 839, 841, 39 W.C.D. 758, 761 (Minn. 1987).  When a rehabilitation plan has been developed, an employee’s failure to cooperate with the plan may result in the discontinuance of temporary total disability benefits.  Boeder v. State, Dep’t of Natural Resources, 63 W.C.D. 634 (W.C.C.A. 2003), summarily aff’d (Minn. Nov. 26, 2003); Bauer v. Winco/Energex, 42 W.C.D. 762 (W.C.C.A. 1989); see also Minn. Stat. § 176.102, subd. 13 (discontinuance of rehabilitation services allowed where the employee does not make a good faith effort to participate in a rehabilitation plan).  In addition, an employee who is attending school outside of retraining is generally considered to have withdrawn from the labor market and is not entitled to wage loss benefits.  Le v. State, Univ. of Minn., 330 N.W.2d 453, 35 W.C.D. 665 (Minn. 1983).  Whether an employee has withdrawn from the labor market is a question of fact for the compensation judge.  Schroeder v. Highway Servs., 403 N.W.2d 237, 238, 39 W.C.D. 723, 725 (Minn. 1987).

In this case, the employee was terminated from his employment on May 22, 2013.  He continued to meet with his QRC and underwent a rehabilitation consultation on May 29, 2013, which resulted in rehabilitation services being provided.  He met with the job placement specialist and signed a job placement plan and agreement dated June 18, 2013.  Our review of the evidence does not support the finding that the employee was not cooperating with rehabilitation services since the only obligation up to that point was to establish a rehabilitation plan.  No other requirements were in place.  We reverse the compensation judge’s denial of temporary total disability benefits from May 23, 2013 through June 18, 2013.

After that date, there is evidence to support the compensation judge’s findings that the employee did not make a good faith effort to participate in the rehabilitation plan and did not conduct a diligent job search.  The employee did not submit job logs as noted in the placement specialist’s records, did not follow up on job leads, and limited his search to his hometown.  The compensation judge recognized that the employee had applied for a few jobs, but found that it was not enough to constitute a diligent job search.  Further, the employee’s rehabilitation plan was suspended in September 2013 due to a rehabilitation dispute and there is no evidence in the record that the employee conducted a diligent job search after that time.  Finally, the compensation judge could reasonably conclude that the employee had voluntarily withdrawn from the labor market when he turned down a job offer because he was attending truck driving school.  See Stever v. Ford Motor Co., 68 W.C.D. 74 (W.C.C.A. 2008) (affirming compensation judge’s finding that the employee had withdrawn from the labor market while attending school).  Substantial evidence supports the compensation judge’s denial of temporary total disability benefits after June 18, 2013.^[1]

In conclusion, we affirm the compensation judge’s determinations that the employee was not under physical restrictions due to the hernia injury and was not entitled to temporary total benefits.  We reverse her determinations that the employee did not cooperate with rehabilitation from May 23 through June 18, 2013 and that the Allina treatment of July 17, 2013 was not compensable and hold that treatment of the employee’s diabetes is reasonable required to treat the work-related hernia injury.