AARON CROSBY, Employee/Respondent, v. TAK COMMC’NS, INC. and AUTO-OWNERS INS. GROUP, Employer-Insurer/Appellants, and MEDICA HEALTH PLANS, UCARE, and ESSENTIA HEALTH-DULUTH, Intervenors.

The employer and insurer appeal the compensation judge’s award of medical and chiropractic treatment, reimbursement and payment of intervention claims, and reimbursement of medical mileage and out-of-pocket expenses. We affirm.

On February 1, 2012, the employee, Aaron Crosby, was employed as a cable installer for the employer, TAK Communications, Inc. (“TAK”). He sustained a concussion and injury to his spine when he was struck on the top of the head by an overhead garage door being closed by a co-worker. He presented at the emergency room with complaints of neck pain, dizziness, and lightheadedness. He was prescribed pain medication and was advised to avoid physical labor but could tolerate limited desk work. He obtained follow-up treatment at Allina Health Clinic, primarily with Dr. Karla Kammueller, who continued his pain medication regimen and work restrictions. With ongoing concussive symptoms, the employee was referred to a neurologist.

The employee was seen for a neurological evaluation at Noran Neurological Clinic by Dr. Rupert Exconde on February 16, 2012. (Ex. D.) Complaints of ongoing neck, mid back, and low back pain were noted, as well as neck and head tightness and concentration and memory issues. Dr. Exconde ordered MRI scans of the head and neck and kept the employee off work until re-evaluation. The brain MRI results were normal and the cervical MRI showed a mild disc herniation, for which the employee was referred to Physicians’ Diagnostic and Rehabilitation Center for MED-EX physical therapy overseen by Dr. Thomas Kraemer.

Despite spinal rehabilitation, the employee’s low back pain continued. He underwent MRI scans of the thoracic and lumbar spine in April 2012, the latter showing spondylolysis at L5. By June 2012, the employee reported some improvement from the rehabilitation program. (Exs. K and I.) Dr. Kammueller kept the employee off work during rehabilitation, but released him to supervisory work with no lifting on June 7, 2012. The employee testified to working long hours, but with activity limitations and office-related ergonomic corrections. (T. at 48.)

The employee completed spinal therapy in August 2012. Significant improvement was noted, but the employee continued to report persistent pain. (Exs. D and I.) Dr. Kraemer considered the employee ready to work without restrictions. (Ex. I.) On August 8, 2012, Dr. Kammueller released the employee from work restrictions. (Ex. K.) The employee was referred for a surgical evaluation to Dr. Edward Santos, who noted that the employee’s pain was aggravated with any form of physical activity and work throughout the day but that surgery was not indicated. Dr. Exconde considered the employee to have reached maximum medical improvement as of September 12, 2012. The employee was again seen by Dr. Exconde in March 2013 with a recurrence of pain, which Dr. Exconde attributed to the employee working full-time.

The employer and insurer admitted the employee’s February 1, 2012, work injury and paid wage loss and medical benefits. Based upon ratings provided by Dr. Exconde in reports dated November 21, 2012, and March 12, 2013, the employee claimed entitlement to permanent partial disability benefits for the cervical, thoracic, and lumbar spine. (Ex. M.) The employer and insurer denied the employee’s claim and the issue came before a compensation judge. By Findings and Order dated November 18, 2013, the judge awarded permanent partial disability benefits in the amount of 15.6723 percent for the combined ratings, adopting the opinions and ratings of Dr. Exconde. Further, the judge found the employee continued to experience symptoms in his neck and back since his 2012 work injury despite having reached maximum medical improvement and having been released to work without restrictions. These findings were not appealed.

The employee’s employment with TAK ended in November 2013 and the employee relocated to North Carolina for approximately two years. There he did some cable installation and electric work. He returned to Minnesota in late 2014 and began doing cable installation work that was physically demanding. He suffered an injury to his left knee in April 2015. He did not seek medical treatment for his neck or back between 2013 and 2015, but testified to having had ongoing pain during that time. (T. at 49, 54, and 62.) The employee also testified that since returning to work following the 2012 work injury, he has been able to perform physically demanding tasks but not without pain. (T. at 52, 54-55, 62, and 80.)

In 2015, the employee sought treatment at Essentia Health in Duluth for a variety of issues, including knee, hip, and groin pain, as well as ongoing back pain. In October 2015, he reported that his back pain was worsening. He underwent a lumbar MRI which showed facet arthropathy at L4-5. The employee was doing physical therapy to strengthen his lower extremities, and began treating with a chiropractor, Steven Lukovsky, D.C., in December 2015. The employee received chiropractic treatments into 2016, which he reported as helpful.

On April 18, 2016, the employee saw Dr. Exconde for further evaluation of his back pain. (Ex. D.) The employee had been working as an attendant at a parking ramp since the previous July and Dr. Exconde noted repetitive lateral twisting at that job. The employee also reported declining cognitive function and memory difficulties. Dr. Exconde recommended that the employee continue with chiropractic care and physical therapy, and referred the employee for a neuropsychological evaluation, which took place on April 25, 2016, with Dr. Maida Gunther. Dr. Gunther concluded that the neuropsychological testing results were within normal limits, though she expressed concern regarding possible anxiety and depression.

In 2016, the employee underwent multiple surgeries, including repair of bilateral inguinal hernias and bilateral hip labral tears. During that time, Dr. Exconde deferred further evaluation of back pain until those surgeries were completed. (Ex. D.)

On February 14, 2017, the employee presented with low back pain at Essentia Health. He was referred for a SpineX program evaluation. In the spring of 2017, the employee reported cervical, mid and low back pain since his 2012 injury with occasional radiating symptoms in both legs. The pain was described as constant, achy, and tight, and was aggravated with bending, lifting, and prolonged standing. The employee began treating with chiropractor, Adam Sundberg, D.C., in May 2017. He was seen on only a few occasions but did report some improvement in his symptoms. After continued physical therapy, the employee was seen for a follow-up evaluation for low back pain at Essentia Health by Dr. Stefan Kaiser. The employee was also reporting ongoing hip issues such that Dr. Kaiser did not believe the employee was yet a candidate for the SpineX program until his hip issues resolved. In late 2017, Dr. Kaiser noted that the employee had started a job detecting underground cables and was doing well in that position. At a March 6, 2018, follow-up visit, Dr. Kaiser believed the employee to be ready for the SpineX program.

With regard to the medical treatment rendered to the employee’s neck and back from 2015 to 2017, it was Dr. Exconde’s opinion that the 2012 work injury was a substantial contributing factor. (Ex. N.) By letter, he was specifically asked whether the October 2015 MRI, April 18, 2016, office visit, and the neuropsychological testing were reasonable and necessary, and Dr. Exconde responded in the affirmative but without further explanation.

For purposes of an independent medical examination, the employee was seen by Dr. Paul Cederberg in August 2017. It was Dr. Cederberg’s opinion that the employee’s February 2012 injury had resolved when he reached maximum medical improvement in November 2012,^[1] noting that the employee had returned to work without restrictions and the gap in treatment between 2013 and 2015. Dr. Cederberg also opined that the employee’s bilateral hip condition was not causally related to the work injury. (Ex. 2.)

The employee sought payment for various medical bills dating back to 2015. The employer and insurer denied liability, citing the opinions of Dr. Cederberg. The matter came on for hearing before a compensation judge on March 21, 2018. Relying primarily on the testimony of the employee that he had never fully recovered from the injury and suffered ongoing pain, the submitted opinions and treatment records of Dr. Exconde, and other medical records in evidence, the compensation judge found the claimed treatment to be reasonable, necessary, and causally related to the employee’s work injury. She ordered payment of the outstanding treatment, reimbursement to intervenors, and payment to the employee for claimed medical mileage and out-of-pocket expenses.

The employer and insurer appeal.

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).

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 employer and insurer appeal the compensation judge’s award of the employee’s claim for medical and chiropractic treatment, reimbursement and payment of intervention claims, and reimbursement of medical mileage and out-of-pocket expenses, alleging that substantial evidence in the record does not support the award, and that the compensation judge erred in adopting the opinions of the treating physician over those of the independent examiner.

The employer and insurer argue that the compensation judge erred in accepting the opinions of Dr. Exconde over those offered by Dr. Cederberg because Dr. Exconde’s opinions lack foundation. We disagree.

The employee began treating with Dr. Exconde within weeks of his February 1, 2012, work injury. He continued to treat with Dr. Exconde on a regular basis until relocating to another state. Upon returning to Minnesota and experiencing an increase in his symptoms, the employee returned to see Dr. Exconde in the spring of 2016. The employee testified that he returned to Dr. Exconde because of the doctor’s familiarity with the employee, his medical history, and the work injury. (T. at 69, 82-83.)

The employer and insurer argue that Dr. Exconde’s January 2018 report should have been rejected by the judge because it is not a narrative report and does not specifically address more recent physical therapy and chiropractic treatment claimed by the employee. There is no legal requirement that medical expert opinion be submitted in the form of a narrative report, and the compensation judge was well within her discretion to consider Dr. Exconde’s report as submitted in conjunction with years of his treatment records. With regard to the 2017 physical therapy and chiropractic treatment, Dr. Exconde was aware of the employee’s ongoing physical therapy and chiropractic treatment, and recommended in April 2016 that he continue with those treatment modalities to address his back pain. The employer and insurer also argue that Dr. Exconde had no basis to opine regarding the neuropsychological referral. However, Dr. Exconde’s referral was made upon complaints by the employee of memory and cognitive issues, which were a continuation of the same symptoms noted and addressed by Dr. Exconde when treating the employee in 2012. The employer and insurer also allege Dr. Exconde’s opinions lack foundation because he was not aware of the physical nature of the employee’s work or the circumstances of his return to work. To the contrary, Dr. Exconde specifically cited the employee’s return to work as a reason the employee was experiencing symptoms in March 2013, over a year after the date of injury. (Ex. D.)

Given Dr. Exconde’s treatment of the employee since 2012, his knowledge of the employee’s history and the work injury, and his review of some, though not all, of the employee’s treatment records from other providers, we conclude Dr. Exconde had adequate foundation. See Scott v. Southview Chevrolet Co., 267 N.W.2d 185, 30 W.C.D. 426 (Minn. 1978); Groetsch v. Kemp’s, LLC, 76 W.C.D. 775 (W.C.C.A. 2016), summarily aff’d (Minn. Oct. 3, 2016).

It is well established that this court will defer to a compensation judge’s choice between well-founded medical expert opinions. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985). The compensation judge in this case was presented with two opposing medical expert opinions, those of Dr. Exconde and those of Dr. Cederberg. Both doctors had adequate foundation for the opinions offered. We affirm the compensation judge’s choice of expert opinion.

The employer and insurer also argue that substantial evidence in the record does not support the compensation judge’s decision, citing various facts that should have weighed in favor of denying the employee’s claim. Essentially, the employer and insurer allege that because the employee returned to work under the direction of his treating physicians in August 2012, because that work was physically demanding and required long hours, and because he had been placed at maximum medical improvement, his injury had resolved in 2012, and the symptoms he experienced and for which he sought treatment after 2015 were unrelated to the 2012 work injury. The employer and insurer allege that the compensation judge ignored, failed to address, or omitted these facts in her decision. We are not persuaded.

The compensation judge concluded that the employee’s symptoms and treatment rendered since 2015 are related to his 2012 work injury, citing the opinions of Dr. Exconde and the credible testimony of the employee. As noted above, we conclude the opinions of Dr. Exconde were well-founded and the judge’s adoption of those opinions was appropriate. The judge found credible the employee’s testimony that his symptoms have been ongoing and that he limited and made modifications to his work and activities as a result. The assessment of credibility is within the purview of the compensation judge. Even v. Kraft, Inc., 445 N.W.2d 831, 42 W.C.D. 220 (Minn. 1989). The opinions of Dr. Exconde and the credible testimony of the employee constitute substantial evidence in the record to support the compensation judge’s decision.

We reject the employer and insurer’s argument that the compensation judge ignored, failed to address, or omitted facts in her consideration of this case. A compensation judge’s decision need not cite to every fact in the record. See Regan v. VOA Nat’l Housing, 61 W.C.D. 142 (W.C.C.A. 2000). Contrary to the employer and insurer’s assertions, the memorandum indicates that the compensation judge was aware that the employee resumed his cable installation work after the work injury, and she mentions the employee having attained maximum medical improvement in her discussion of the opinions of Dr. Cederberg. It is clear that the judge carefully considered the employee’s testimony and reviewed the medical records in evidence in making her decision. Though she may not have discussed in detail evidence that would support a denial, the judge concluded that the weight of the evidence as a whole supported the claims of the employee, which was within her sound discretion. See Sanchez-Rivera v. Swift Pork Co., No. WC18-6182 (W.C.C.A. Oct. 31, 2018). This court will not disturb the findings of a compensation judge unless they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole. Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 229 N.W.2d 521 (1975). Because the judge’s findings in this case are not manifestly contrary to the weight of the evidence and are reasonably supported by the evidence as a whole, we affirm.