THERESA M. (GARRETT) HOVDE, Employee/Appellant, v. VILLS. OF N. BRANCH and SFM, Employer-Insurer/Respondents, and ABBOTT NW. HOSP., FAIRVIEW HEALTH SERVS., UCARE, CAMBRIDGE MED. CTR., NORAN NEUROLOGICAL CLINIC, EYE CARE ASSOCS., P.A., Intervenors.

The employee appeals the compensation judge’s determination that the employee’s work injury of February 23, 2014, was temporary and fully resolved by April 6, 2014, and the denial of the employee’s claim for benefits after that date. We affirm.

Theresa M. Hovde was employed as a certified nurse assistant (CNA) by Villages of North Branch on February 23, 2014. As she was coming into work on that day, she slipped on ice and fell backwards, striking her head on the ground. After the incident, the employee went to the emergency department at Fairview Lakes Medical Center with complaints of pain in her head and neck. A large hematoma on the back of her head was noted. Ms. Hovde stated she was dazed after the fall but did not lose consciousness. A head CT scan taken that day showed no acute intracranial pathology and a cervical spine CT scan indicated no acute fracture. According to the chart notes, she denied any visual disturbances. She was given pain medication and discharged with an assessment of “closed head injury, concussion without [loss of consciousness], scalp contusion, cervical strain.”^[1]

The employee followed up with her primary care physician, Dr. Terry Kopp, advising him that she had “a lot of headaches and neck pain” along with some dizziness. Dr. Kopp’s impression was “strain of neck muscles” and “concussion without loss of consciousness.”^[2] Dr. Kopp took the employee off work. The employer and insurer admitted liability for the work injury and began payment of temporary total disability benefits and medical expenses.

The employee was referred by Dr. Kopp to a neurologist, Dr. Kenneth Hoj, and saw him on March 13, 2014. She reported constant headaches with throbbing pain, nausea with some dizziness, and vision difficulties. Dr. Hoj prescribed nortriptyline for her headaches and recommended a brain MRI scan and a head MR angiogram. The scans were done on April 1, 2014, and were read as being normal. Ms. Hovde continued to treat with Dr. Kopp, primarily with medication management. She also received physical and occupational therapy under Dr. Kopp’s supervision.

Dr. Kopp also referred the employee to a psychologist, Dr. Kyle Harvison, for a neuropsychological consultation. The employee first saw Dr. Harvison on August 25, 2014, with her primary symptom of daily intense headaches. She also complained of photosensitivity, difficulty being around crowds, and problems with comprehension. On what she called bad days, she stated she was barely able to get out of bed. Dr. Harvison recommended a neurology consultation with a headache specialist at the Noran Neurological Clinic and a neuro-ophthalmology consultation, as well.

Dr. Harvison conducted a neuropsychological assessment including a number of tests on November 11, 2014. Dr. Harvison concluded:

Dr. Harvison referred the employee to Dr. Michael Sethna at the Noran Neurological Clinic on October 13, 2014, “for evaluation of postconcussive headaches and encephalopathy.”^[5] After his examination, Dr. Sethna was of the opinion that the employee’s headaches might be due in large part to “tight muscles in the neck.”^[6] He provided occipital nerve blocks and the employee noted immediate complete relief. Dr. Sethna’s impression was that “[the employee’s] response to the occipital blocks in the office, effectively mandate that 100% of her headache and tinnitus, arises not from damage to the structures inside the skull but to tight, sore structures outside the skull.”^[7] Dr. Sethna prescribed “antispasticity” medication. Dr. Sethna ordered a cervical spine MRI scan which was performed on April 19, 2015, and showed normal cervical lordosis, no fracture or spondylothesis, mild narrowing off the spinal canal at C4-7, and moderate foraminal narrowing with possible impingement at C6 and C7 nerve roots. In June 2015, Dr. Sethna released the employee to work eight hours a day, up to 30 hours a week on a sedentary basis, with no lifting over 10 pounds and minimal use of her arms above her head.

At the request of the employer and insurer, the employee was evaluated by Dr. Khalafalla Bushara, who generated a report dated April 20, 2015, setting out his history from the employee, his review of records, his examination of the employee, and his conclusion. It was Dr. Bushara’s opinion that the employee sustained a closed head injury that “resolved within a few weeks as is typical for this type of injury.”^[8] The employee, according to Dr. Bushara, also had a “sprain/strain injury of the cervical spine which again was temporary and has resolved.”^[9] Dr. Bushara stated that the employee’s symptoms were subjective complaints not substantiated by objective findings or physiological parameters, and that no work restrictions or medical treatment after six weeks from the date of injury were appropriate or related to the employee’s work injury. Dr. Bushara wrote a supplemental report on June 30, 2015, after reviewing additional medical records as well as a surveillance video. He concluded that the additional records did not change the opinions set out in his earlier report. He also noted that he believed the surveillance showed “evidence for a normal gait and no pain behavior.”^[10]

At the referral of Dr. Harvison, Ms. Hovde began treating at Eye Care Associates with Dr. Marian Rubenfeld, a neuro-ophthalmologist. Dr. Rubenfeld sent a report to the employee’s attorney dated April 28, 2016, responding to Dr. Bushara’s deposition testimony. Contrary to Dr. Bushara’s opinion, Dr. Rubenfeld stated the employee’s reported visual difficulties, labeled as secondary convergence insufficiency, gaze dysmetria, photophobia, and headaches, as well as cognitive issues, were characteristic of a traumatic brain injury, caused by the “shearing forces of deceleration/acceleration experienced by the central nervous system during the accident.”^[11] Dr. Rubenfeld also opined that the services provided to the employee were reasonable and related to the work injury.

The employee’s attorney had her evaluated by a psychologist, Dr. C. Joe Egli, on April 29, 2016. In addition to an interview and questionnaire, the employee was asked to complete a number of tests. Afterwards, in his report, Dr. Egli diagnosed the employee’s condition as Unspecified Neurocognitive Disorder. His recommendations included playing board games to improve “working memory, mental task-shifting, organization, and inhibition.” She was also encouraged to “create a lifestyle that will help her organize her world” and “practice good mental hygiene.”^[12]

In a follow-up report dated May 9, 2016, Dr. Sethna responded to Dr. Bushara’s reports and deposition. He reiterated his conclusion that the employee’s work injuries had not resolved. He also restated his opinion that the occipital nerve blocks he had provided were a significant factor in Ms. Hovde’s improved condition and ability to return to work. He also cited to studies supporting his opinion on these issues.^[13]

The employee was also seen for an independent medical examination by Dr. Alan Weingarden, a neuro-ophthalmologist on June 28, 2016. Dr. Weingarden reviewed the medical records, including those of Dr. Rubenfeld. Dr. Weingarden opined that the employee’s vision issues were not related to the work injury, but instead represented a “congenital exophoria/exotropia.”^[14]

Dr. Robert Doss provided a neuropsychological evaluation on behalf of the employer and insurer. In his report, dated August 31, 2016, Dr. Doss recorded his review of medical records from multiple providers and examiners, the history provided by the employee, and the results of 20 tests, all “designed to assess a wide range of neurocognitive abilities.”^[15] He concluded the employee met “DSM-V criteria for Unspecified Neurocognitive Disorder, Rule Out Somatic Symptom Disorder.”^[16] In response to specific questions, Dr. Doss attributed any neurocognitive deficit to issues pre-existing the work injury and he stated the work injury was not a factor in his evaluation of the employee’s condition.

Dr. Bushara’s deposition was taken for the hearing on January 26, 2016. Dr. Bushara noted at the outset that he had reviewed additional medical records from the Noran Clinic and other facilities after his last report in June 2015. He testified that the employee’s complaint of seeing double, even when looking with one eye, was not physiological. Similarly, although occipital blocks might be of some aid in easing tinnitus, he opined that the condition was completely subjective and an occipital block would not result in the complete relief that the employee had described to Dr. Sethna. Dr. Bushara restated his opinion that the employee’s injury on February 23, 2014, was a mild closed-head injury which had resolved.^[17]

Dr. Bushara prepared a supplemental report of August 12, 2016, after reviewing additional medical records and reports, including Dr. Sethna’s reports. Dr. Bushara restated his opinion that the employee’s “subjective complaints could not be explained by objective findings that would indicate a nervous system lesion resulting from traumatic brain injury.”

Based on Dr. Bushara’s report in April 2015, the employer and insurer filed a notice of intention to discontinue benefits. The employee had filed a claim petition for benefits in March 2015 and subsequently filed an objection to the discontinuance in July 2015. The pleadings were consolidated for hearing.

A hearing on the consolidated pleadings was held on October 27, 2016. In Findings and Order served and filed on January 9, 2017, the compensation judge determined that the employee’s February 23, 2014, work-related injury had fully resolved by April 6, 2014. The employee’s claim for benefits and medical expenses after that date was denied. The employee appeals.

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(3). 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).

The employee raises a number of arguments in her appeal: first, that the compensation judge failed to consider critical evidence and made his own medical opinions; second, that Dr. Bushara’s opinion did not have adequate foundation and was not supported by other evidence; third, that the compensation judge erred by not ordering payment for a cervical MRI scan in April 2015; and fourth, that substantial evidence does not support the judge’s finding that the employee’s work-related injury had resolved by April 6, 2014.

In this argument, the employee states that there were medical reports not mentioned by the compensation judge in his findings and memorandum and also that there was evidence “missing” from the compensation judge’s decision. The employee refers specifically to chart notes from occupational therapy in which the employee participated beginning in January 2015, and to Dr. Egli’s report. The implication is that the compensation judge did not consider all of the evidence presented to him or this information would have been mentioned.

We note that “[a] compensation judge is not required to refer to or discuss every piece of evidence introduced at the hearing.” Regan v. VOA Nat’l Hous., 61 W.C.D. 142, 149 (W.C.C.A. 2000), summarily aff’d (Minn. Apr. 6, 2001); see also Ruby v. Casey’s Gen. Store, 71 W.C.D. 535 (W.C.C.A. 2011), summarily aff’d (Minn. Sept. 28, 2011); Lowell v. Lee Stamping, 63 W.C.D. 304 (W.C.C.A. 2003), summarily aff’d (Minn. Apr. 29, 2003). The rationale for the rule is demonstrated by the present case. The central issue in this case, as stated by the parties, was the nature and extent of the head injury sustained by the employee on February 23, 2014. To determine that complex issue, the parties introduced for the compensation judge’s consideration, a number of expert medical reports, a medical deposition, records from medical providers, rehabilitation records, surveillance reports and video, and articles from various periodicals on the issues. In addition, the compensation judge conducted a hearing with four witnesses resulting in a transcript of more than 100 pages.

The information, which the employee claimed in her brief had been ignored, was provided to the physicians who rendered opinions on the central issue of what consequences resulted from the work injury. Dr. Sethna wrote three reports supporting the employee’s claim, and there was no mention in any of those reports of either the occupational therapy notes or Dr. Egli’s report. Dr. Bushara’s deposition was taken and he was not cross-examined on these subjects. Further, Dr. Bushara reviewed Dr. Egli’s testing in his August 12, 2016, report and stated that it did not change his original opinions. We do not accept the employee’s contention that the evidence was “critical” and necessitated discussion by the compensation judge. The compensation judge did not err by failing to discuss each piece of evidence in his findings and order or memorandum.

The employee claims the compensation judge’s “issuance of expert medical opinion is outside his duties as trier of fact.”^[18] This argument is based on comments the compensation judge made in discussing the medical evidence in Findings 4 through 12. We find no expression of personal medical opinions in those comments. Instead, the compensation excerpted statements from the exhibits that he found significant. Any conclusion that the comments represented medical opinions expressed by the compensation judge is simply a misreading of the findings and order.

In reaching his decision, the compensation judge specifically adopted the opinion of Dr. Bushara.^[19] In her appeal, the employee claims that Dr. Bushara lacks the qualifications to express opinions on “psychological, orthopedic, and neuro-ophthalmologic matters,”^[20] and alleges the compensation judge erred in relying on Dr. Bushara’s opinion. We disagree.

Contrary to the employee’s argument, Dr. Bushara did not express a psychological, neuro-ophthalmologic, or orthopedic diagnosis. Dr. Bushara conducted a neurological examination of the employee. He found no objective evidence of an ongoing head or neck injury. He found no neurologic explanation for the employee’s claimed gait and vision issues. His opinion was that the employee’s subjective complaints were not supported by objective findings and that certain of the subjective complaints, such as her reported double vision in one eye, had no physiological basis. His conclusion was that the employee’s physical injury had resolved. The compensation judge found Dr. Bushara’s opinion to be supported by the normal brain MRI scan done on April 1, 2014, the equivocal findings of the cervical MRI done on April 19, 2015, the neuropsychological testing done by Dr. Harvison in November 2014, the surveillance video and reports, and the IME opinions of Drs. Weingarden and Doss.

The question then, for this court, is whether the compensation judge was correct in finding that Dr. Bushara’s opinion had adequate foundation so as to be accepted and relied upon. A medical opinion must have adequate foundation for it to be relied upon by the compensation judge. Foundation depends, first, on whether the expert who provides the report is competent to discuss the subject at issue. Competency of a witness to provide an expert opinion “depends upon both the degree of the witness’ scientific knowledge and the extent of the witness’ practical experience with the matter which is the subject of the offered testimony.” Reinhardt v. Colton, 337 N.W.2d 89, 93 (Minn. 1983). However, the “qualifications of an expert do not usually go to the admissibility of the expert’s opinion but merely to its weight.” Ruether v. State, Mankato State Univ., 455 N.W.2d 475, 477, 42 W.C.D. 1118, 1121 (Minn. 1990); see also Willy v. Northwest Airlines Corp., 77 W.C.D. 349 (W.C.C.A. 2016), summarily aff’d (Minn. May 10, 2017). Dr. Bushara is a board-certified neurologist who was asked to provide a neurological opinion. We conclude that Dr. Bushara had the requisite competence to express his opinion as set forth in his deposition and reports.

The second part of foundation for an expert opinion is whether the expert has sufficient knowledge of the facts. Here, Dr. Bushara conducted an examination, took the employee’s history, and reviewed numerous medical reports and records, as itemized and discussed in his reports of April 20 and June 30, 2015. Dr. Bushara had adequate knowledge of the information in this matter “to form a reasonable opinion that is not based on speculation or conjecture.” Gianotti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 802, 77 W.C.D. 117, 124 (Minn. 2017).

The employee also argues that the compensation judge erred by finding that other evidence in the record supported Dr. Bushara’s opinions because Dr. Bushara did not base his opinions on this evidence, some of which pre-existed his report. We disagree. The compensation judge did not condition his acceptance of Dr. Bushara’s opinions on the other evidence cited by the employee, including the opinions of Drs. Doss and Weingarden, but used consistencies in the evidence to support his finding that Dr. Bushara’s opinions were more persuasive and his adoption of these opinions.

The employee further contends that the compensation judge erred by stating that Dr. Harvison’s medical records support Dr. Bushara’s opinions because Dr. Harvison’s opinions were based on invalid neuropsychological testing. This is a misstatement of the compensation judge’s Finding 8 regarding Dr. Harvison’s opinion. In that finding, the judge noted that Dr. Harvison had found the employee’s performance on the testing was invalid and was therefore suggestive of a somatoform disorder. Dr. Harvison did not base his opinion on invalid testing; he concluded that the employee’s performance during the testing indicated somatoform disorder. The compensation judge could reasonably conclude that Dr. Harvison’s report supports Dr. Bushara’s opinions. The judge did not err by determining that other evidence in the record supported Dr. Bushara’s opinions or by relying on his opinions.

As a separate issue, the employee argues that it was legal error for the compensation judge not to order payment of the cervical MRI in April 2015. Since the compensation judge determined that the employee’s work injury was fully resolved by April 6, 2014, we find no basis to order payment of an MRI scan that was performed a year later.

The employee contends that Dr. Bushara’s opinions are incorrect and the compensation judge’s reliance on those opinions warrants reversal. However, it is apparent from the compensation judge’s findings that he considered not only the medical evidence but also the employee’s testimony and the surveillance video in reaching his decision. As to the medical reports, it is the responsibility of the compensation judge to choose between competing medical opinions and generally a decision based on that choice will be affirmed if the opinions relied upon have adequate foundation. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); Smith v. Quebecor Printing, 63 W.C.D. 566 (W.C.C.A. 2003), summarily aff’d (Minn. Aug. 15, 2003). We see no reason to depart from that general rule here.

Substantial evidence supports the compensation judge’s finding that the employee’s work-related injury of February 23, 2014, had resolved by April 6, 2014. Accordingly, we affirm the decision of the compensation judge.