The employee, the appellant in this matter, appeals from the compensation judge’s findings that the employee’s proposed medial branch block injections, piriformis Botox injection, and ongoing prescription expenses to treat the employee’s low back condition are not reasonable and necessary to cure and relieve the employee of the effects of her April 16, 2010, work injury.  The employer and insurer maintained that the compensation judge’s decision is supported by substantial evidence in the record.  We affirm.

The employee was working as a home health aide for the employer, Hospice of the Twin Cities, when she suffered an admitted low back injury on April 16, 2010.  Initially, the employee was kept off work and then returned to work with restrictions.

On May 27, 2010, the employee underwent an MRI scan, which showed moderate disc degeneration with 5 mm extruded left paracentral disc herniation at the L5-S1 level.  Epidural steroid injections were performed.  After sixteen weeks of conservative care without a reduction of the employee’s pain symptoms, she was referred to Stephano Sinicropi, M.D., for a surgical consultation.  On August 16, 2010, the employee underwent a decompressive discectomy at L5-S1.  The employee experienced continued back pain following the surgery.  A TENS unit was implanted and medial branch blocks were performed.  The employee underwent a discogram.  On May 21, 2012, the employee underwent anterior spinal decompression and L5-S1 disc replacement.^[1]

The employee’s disc replacement did not relieve her ongoing lumbar pain.  She also experienced left radicular pain symptoms after the surgery.  The employee underwent facet block injections which provided one day of relief.  The employee also underwent physical therapy, but she did not experience pain relief through this conservative approach.^[2]

On April 4, 2013, the employee was examined by Matthew Monsein, M.D., regarding possible pain clinic care.  The employee declined to participate in the program, citing her difficulties swimming.^[3]

On May 1, 2013, the employee was examined by Steven Trobiani, M.D.  Dr. Trobiani diagnosed left piriformis syndrome resulting in the compression of the sciatic nerve and left radiculopathy.  Starting on June 6, 2013, the employee underwent a series of lumbar injections which afforded her significant pain relief.^[4]  On July 8, 2013, the employee received a left piriformis muscle injection (Botox).  The employee obtained significant and long-lasting pain relief through that injection.^[5]  In August 2013, the employee received trigger point injections administered by Dr. Trobiani, but the employee’s lumbar pain and radicular symptoms persisted.  A CT scan conducted on August 29, 2013, showed bilateral moderate facet arthropathy at L5-S1 and mild right facet arthropathy at L4-L5.^[6]

For pain relief between the injections, Dr. Trobiani prescribed an opioid medication, Percocet, which the employee took three times daily.  On August 23, 2013, Dr. Trobiani added another opioid medication, OxyContin, to the employee’s pain medications.  The employee took gabapentin for a time but discontinued that by July 2015.^[7]  The employee received facet injections from Dr. Trobiani on October 29, 2013, resulting in moderate pain relief.^[8]

On June 13, 2014, Dr. Trobiani examined the employee and proposed a rhizotomy procedure to address her ongoing low back pain.  Dr. Trobiani assessed the employee’s opioid medication usage and maintained her dosage.  On August 18, 2014, the employee was examined due to an increase in low back and left lower extremity pain.  Dr. Trobiani noted marked tenderness over the employee’s left piriformis resulting in pain extending to her left foot.  Dr. Trobiani assessed the employee’s current condition as resulting from the Botox injection wearing off and he proposed repeating that injection.  The employer and insurer refused approval of both the proposed rhizotomy procedure and the Botox injection.  To address the employee’s pain symptoms, Dr. Trobiani increased the dosages of the employee’s opioid medication.^[9]

On October 23, 2014, the employee underwent an independent medical examination (IME) conducted by Joel I. Gedan, M.D.  Dr. Gedan reviewed the employee’s medical records and conducted a physical examination.  Dr. Gedan noted that the employee was taking an opioid, Opana (oxymorphone), twice daily for pain relief, in addition to Percocet and gabapentin.  The employee described her pain as 9 of 10 at the time of the IME.  Dr. Gedan observed mild to moderate decreases in range of motion (ROM) in the employee’s low back flexion, extension, and lateral bending.  No deficits were observed in the employee’s gait.  Dr. Gedan opined that the proposed rhizotomy workup was not reasonable or necessary medical care for the employee as she experienced ongoing radiculopathy and she had a failed medial branch block test.  Dr. Gedan relied upon the treatment guidelines of the American College of Occupational and Environmental Medicine in arriving at this conclusion.^[10]

In addition to his opinion regarding the proposed rhizotomy, Dr. Gedan also opined that the Botox injection procedures prescribed by Dr. Trobiani were not reasonable or necessary.  Dr. Gedan maintained that piriformis syndrome was a controversial diagnosis.  Dr. Gedan also opined that the opioid medication regime that the employee was using was unsafe, amounting to “almost 500 morphine equivalent doses per day.”  Dr. Gedan recommended weaning the employee from all opioid medications.^[11]

On November 12, 2014, Dr. Gedan supplemented the earlier IME with an addendum in which he reiterated his opinion that Dr. Trobiani’s treatment was neither reasonable nor necessary.  Dr. Gedan further opined that additional treatment in the form of specialist care to wean the employee off of narcotic medications was reasonable and needed.^[12]

On February 19, 2015, Dr. Trobiani supplied a narrative report describing his treatment of the employee, and further explaining his proposed rhizotomy workup.  Dr. Trobiani described his prescription of opioid medication as necessary to control the employee’s pain.  In support of his diagnosis of left piriformis syndrome subsequent to lumbar disc replacement, Dr. Trobiani provided an abstract of a medical journal article.^[13]

On February 26, 2015, Dr. Gedan provided an additional supplement to his IME.  Dr. Gedan reviewed Dr. Trobiani’s narrative summary.  Dr. Gedan reiterated and expanded on his opinion regarding the diagnosis of piriformis syndrome.  Dr. Gedan disputed Dr. Trobiani’s assessment of the June 6, 2013, injection.  Dr. Gedan reiterated his opinion that the employee’s diagnoses were chronic pain and chronic left lumbar radiculopathy and the best treatment was increased activity and cessation of narcotic medications.^[14]

The parties’ dispute over treatment led to the filing of requests for formal hearing on May 11 and 13, 2015.  The matter was heard before a compensation judge of the Office of Administrative Hearings on July 8, 2015.  The issues to be determined were: 1) whether Dr. Trobiani’s treatment of the employee was reasonable and necessary to cure and relieve the employee of the effects of the work injury; 2) whether the proposed rhizotomy reasonable and necessary; 3) whether the employee’s prescriptions were reasonable and necessary; and 4) whether Dr. Trobiani’s reimbursement interest should be extinguished for failure to intervene.  Ms. Reiners testified in support of her claim.  The employer and insurer relied upon the medical records of the employee introduced into evidence and the IME opinions of Dr. Gedan.

The compensation judge accepted the employee’s contention that Dr. Trobiani’s billings were appropriately presented as a direct claim of the employee, awarded Dr. Trobiani’s billings for office visits, and awarded the employee’s out-of-pocket medication expenses.  The compensation judge denied approval of the rhizotomy procedure and Botox injections, and denied approval for ongoing opioid medication costs.  The compensation judge qualified the denial of ongoing opioid medication costs to exclude such medications when prescribed as part of a medically supervised program to safely withdraw from continued opioid usage, so long as the employee enrolled in that program within 30 days of the date of the Findings and Order.  Additionally, the compensation judge found that “[t]he employer and insurer are not required to pay for future treatment with Dr. Trobiani and Northstar Neurological Clinic.”  The employee appealed the denial of proposed medical treatment and ongoing medication expenses.

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.”^[15]  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.”^[16]  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.^[17]  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.”^[18]  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.”^[19]

The employee contends that the compensation judge improperly relied on the opinion of Dr. Gedan over the opinion of the treating physician, Dr. Trobiani.  Further the employee contends that the only way in which she is able continue to work with the pain of her low back and left leg is through the opioid medication that the compensation judge terminated.  The employer and insurer rely on the standards governing the resolution of conflicts between medical experts and maintain that the compensation judge’s decision is supported by substantial evidence.

The employee bears the burden of proof that medical treatment is reasonable and necessary to cure and relieve from the effects of the work injury.^[20]  Here, Dr. Gedan disagreed with the treatment provided to the employee by Dr. Trobiani.  At the hearing, the compensation judge received evidence that, in essence, constitutes a debate between the two physicians over the employee’s diagnosis and the appropriate course of treatment.

The reasonableness and necessity of medical treatment sought under Minn. Stat. § 176.135 is a question of fact for the compensation judge.^[21]  In arriving at a decision, the compensation judge must resolve conflicts in expert medical testimony, and the judge’s choice of expert opinion is usually upheld unless the facts assumed by the expert in rendering an opinion are not supported by the evidence.^[22]  Where evidence is conflicting or more than one inference may reasonably be drawn from the evidence, the findings of the compensation judge are to be upheld.^[23]

In this matter, the compensation judge credited the opinion of Dr. Gedan in denying the requested medical treatment and disallowing further opioid medications.  Dr. Gedan’s opinions are well founded and provide an adequate basis in the record to support the compensation judge’s conclusions.

We conclude that substantial evidence supports the compensation judge’s determination that the proposed rhizotomy procedure and further opioid medication are not necessary and reasonable to treat the employee’s low back and left leg condition.  For that reason, we affirm the compensation judge’s decision.

This Court notes that the compensation judge placed a time limit on the period in which the employee could enter a pain management program to safely wean off of opioid medications.  While not raised as an issue by the parties, this Court has determined that the compensation judge’s order should be modified to toll the time available to start such a program.  Accordingly, that portion of the Findings and Order is modified to allow the employee to enter a pain management program up to 30 days after the date that this decision becomes final.

Also not raised by the parties on appeal is the portion of the Findings and Order purporting to deny compensability of future billings of Dr. Trobiani or Northstar Neurological Clinic.  The compensation judge lacks authority to issue an order with prospective effect.   Any billing for future medical care must be addressed under the facts present at that time.  To the extent that the compensation judge’s decision was intended to address care not yet provided to the employee, the Findings and Order is of no effect.

Ms. Reiners bore the burden of proof to show that the proposed treatment of her low back and left leg condition was reasonable and necessary.  The evidence was in conflict over that issue.  The compensation judge found the evidence was not sufficient to meet the employee’s burden and denied benefits.  Having carefully reviewed the record, we conclude that the compensation judge’s findings, except as noted above, are supported by substantial evidence and not clearly erroneous.  The single portion of the compensation judge’s Findings and Order that is beyond her authority has been noted and does not constitute a reversible error.  We therefore affirm the compensation judge’s award.