VIRGIL HALL, Employee/Respondent, v. US STEEL CORP. and BROADSPIRE, Self-Insured Employer/Appellant, and ESSENTIA HEALTH, Intervenor.

The self-insured employer appeals the compensation judge’s award of payment for a medical procedure and various medications. As the compensation judge’s decision was supported by substantial evidence, including a well-founded medical opinion, we affirm.

Virgil Hall, the employee, worked for the U.S. Steel Corporation, the self-insured employer, in its locomotive shop. On May 2, 1979, the employee was on the job site using a wrench on a bolt. The wrench slipped from the bolt and struck the employee in the face. He suffered a blowout fracture of the right eye orbit. The self-insured employer admitted the work injury and paid benefits. The employee was diagnosed with sinusitis arising out of the May 2, 1979, work injury. The sinusitis condition interfered with the employee’s ability to work and he received continuing care for the condition, including a series of sinus surgeries. The employee complained of chronic sinus discomfort, headaches, and nausea.

On January 22, 1984, the employee was clearing overhanging ice from a location on the job site using a long metal rod which he estimated weighed 70 pounds. A large chunk of ice dropped, striking the rod that he was using. The rod levered upward and struck the employee under the chin, rendering him unconscious. The employee injured his low back when he fell. The employee was taken off work periodically due to his low back condition for which he received conservative treatment, including a TENS unit. The employee also underwent conservative treatment for neck pain, primarily in the form of chiropractic care. On August 3, 1988, the employee underwent a cervical and upper thoracic CT scan which showed slight narrowing at C4-C5, minimal bulging at C5-C6, and central disc protrusion at C6-C7. The self-insured employer admitted the 1984 work injury and paid benefits.

In 1995, the employee began receiving chiropractic care, primarily to address his low back pain, from Arne Luoma, D.C. Dr. Luoma’s treatment notes indicated that the employee complained of neck pain in addition to his ongoing low back pain. In a narrative treatment summary, Dr. Luoma attributed the employee’s low back pain to the 1984 work injury. The employee continued to receive ongoing chiropractic care.

On September 28, 2012, the employee underwent an independent medical examination (IME) conducted by Gary Wyard, M.D. on behalf of the self-insured employer. Dr. Wyard considered the employee’s presentation of symptoms to be nonanatomic and indicative of significant functional overlay with psychosocial behavior in the presence of normal objective findings. Dr. Wyard considered the employee’s medical treatment to be neither reasonable nor necessary. Dr. Wyard supplemented his opinion in two later reports, issued on October 7, 2012, and April 17, 2014, reiterating his conclusions.

The employee’s counsel arranged an IME of the employee conducted by William P. Fleeson, M.D., on August 27, 2013. Dr. Fleeson reviewed 260 pages of medical records from over a dozen providers and conducted a two-hour examination. The employee described his current symptoms as including headaches, numbness in his right arm, and increased back pain from driving.

Dr. Fleeson noted the employee’s reporting of cervical pain from the 1984 work injury. The employee described his neck pain as continuing from 1984 through present, with temporary relief from chiropractic care. The employee indicated that his treating physicians did not connect the neck condition to the 1984 injury. (Ex. B, at 4-5.) Dr. Fleeson’s review of treatment records noted the employee was receiving chiropractic care for neck pain in 1988 which was attributed to the 1984 work injury (and a handwritten note of uncertain provenance describing the 1979 injury). Chiropractic treatment notes in 1992 from Larry Bridge, D.C., attributed the employee’s neck pain primarily to the 1979 injury, with a worsening of the neck pain following the 1984 injury. (Ex. B, at 14.) Dr. Fleeson noted the 1994 neurosurgical evaluation of Dr. Tenny of Olanthe, Kansas, who described the employee’s report of sharp pain in the posterior neck in 1979, which was treated by chiropractic care. (Ex. B, at 15.) An evaluation by Dr. Kaiser in 2012 includes the employee’s reporting of chronic neck pain following the 1984 work injury. (Ex. B, at 16.)

In regard to the 1984 work injury, Dr. Fleeson opined that the employee’s “symptoms from that time forward were, and continue to be, pain in neck ….” (Ex. B, at 20.) Dr. Fleeson expressly opined that the 1984 work injury was the cause of a long degenerative process in the employee’s cervical spine, documented by imaging conducted in 1992, in addition to the lumbar spine injury that was the focus of the employee’s treatment following the injury. (Ex. B, at 21.) Dr. Fleeson diagnosed the employee with a “1984 injury with loss of consciousness and strain/sprain plus other musculoskeletal and spine injuries as discussed above … cervical spine ….” (Ex. B, at 23.) Dr. Fleeson considered the employee’s work activities to be the cause of the employee’s symptoms, with the exception of ulnar neuropathy and the possible exception of arachnoiditis shown on the employee’s lumbar imaging. (Ex. B, at 23.)

Dr. Fleeson concluded that the employee’s 1979 and 1984 work injuries were the cause of almost all of the employee’s ongoing medical conditions. Dr. Fleeson also concluded the employee was not at maximum medical improvement (MMI), pending the results of medical care proposed by the employee’s treating physician. In the event that the proposed medical care was not pursued, Dr. Fleeson would then consider the employee to be at MMI and permanent ratings were provided for the cervical spine and the lumbar spine. Dr. Fleeson also stated that a rating might be appropriate for chronic pain syndrome. On February 2, 2015, Dr. Fleeson supplemented his earlier opinion, largely critiquing the IME of Dr. Wyard.

In September 2014, the employee began treating with Rolando R. Rosas, M.D., for recurrent frontal sinusitis. On August 15, 2017, Dr. Rosas prepared a narrative report regarding that treatment at the request of the employee’s counsel. Dr. Rosas attributed the employee’s ongoing sinus problems and persistent headaches to the 1979 work injury. The employee’s current sinus condition did not require any work restrictions and Dr. Rosas assessed the employee to be at MMI regarding the sinus injury.

In 2015, the employee began treating with Obioma J. Igboko, M.B.B.S., for pain management. On January 22, 2016, Dr. Igboko conducted radiofrequency ablation of the third occipital nerve (TON) and C3 through C5 medial branches. In 2016, Dr. Igboko noted that bilateral diagnostic blocks at the L3 through L5 medial branches resulted in temporary, complete relief of the employee’s lumbar pain. On November 17, 2016, Dr. Igboko performed medial branch blocks at those levels.

On January 27, 2017, the employee was examined by Joseph Burgarino, M.D., for an IME on behalf of the self-insured employer. Based on his observations, Dr. Burgarino concluded that the employee’s symptoms were feigned or exaggerated. Dr. Burgarino opined that the employee’s 1984 work injury would have completely resolved within six weeks. Dr. Burgarino concluded that the employee’s work injuries had resolved many years ago and that the recent care received, including that provided by Dr. Igboko, was entirely unrelated to the work injuries.

Dr. Igboko provided a narrative report on the employee’s cervical condition on August 17, 2017, at the request of the employee’s counsel. Dr. Igboko opined that the cervical radiofrequency ablation treatments would provide up to a year of pain relief. Dr. Igboko maintained that the employee’s treatment was necessary and reasonable. Dr. Igboko declined to offer an opinion regarding causation of the employee’s cervical spine condition. The reasonableness of future treatment was considered to be dependent on the duration of pain relief experienced by the employee.

On November 3, 2017, the employee underwent radiofrequency neurolysis at C2 through C5 on the right side, directed by Dr. Igboko. The next month he repeated the same procedure on the employee’s left side at C2 through C5. The procedure provided lasting pain relief.

The employee underwent radiofrequency lesioning at C2 through C5 on the right side in July 2018. The procedure was performed on the left side at those levels the next month. The left-side procedure provided lasting relief. The employee continued to experience cervical pain on the right side, radiating into the shoulder girdle. On August 20, 2018, the employee underwent trigger point injections to address his ongoing cervical pain.

The employee sought payment for Dr. Igboko’s treatment, for chiropractic care received, and for out-of-pocket medication expenses incurred. An administrative conference under Minn. Stat. § 176.106 was conducted, and a request for formal hearing was made. On October 30, 2018, the matter came on for hearing before a compensation judge. The judge found that the medications claimed were reasonable to relieve the employee’s ongoing symptoms. He further found that the radiofrequency ablation procedure conducted by Dr. Igboko was reasonable and necessary treatment for the employee’s work injury. The judge awarded reimbursement for that procedure and the employee’s out-of-pocket prescription expenses. The claim for chiropractic care was denied. The judge’s Findings and Order did not make an explicit statement that either the 1979 or 1984 work injury was the cause of the employee’s condition for which the medical care was awarded. The self-insured employer appealed the Findings and Order.

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 self-insured employer contends that the radiofrequency neurotomy of the employee’s cervical spine performed on November 3, 2017, by Dr. Igboko was not reasonable or necessary or causally related to the employee’s work injuries, that the employee’s claims for medications should be denied, and that the compensation judge’s findings fail to address the issue of causation or otherwise support the judge’s ultimate legal conclusion. The employee maintains that substantial evidence supports the judge’s decisions regarding the medical procedure and the medications. We agree and affirm.

The self-insured employer asserts that the employee’s May 2, 1979, and January 22, 1984, work injuries have resolved and therefore neither the medical procedures nor the claimed medications are compensable. The compensation judge, relying on the medical record, well-founded medical opinion, and the employee’s testimony, found that the employee continues to suffer from neck pain that the employee identified as arising from those work injuries. This constitutes substantial evidence that supports the determination in this matter. Flores v. Sibley Manor, slip op. (W.C.C.A. Jun. 30, 1992).

The self-insured employer maintains that the findings in this matter do not sufficiently analyze the issue of causation raised at the hearing. While there is no mention of Dr. Fleeson’s opinion in the Findings and Order, the compensation judge is not required to refer to every piece of evidence introduced at hearing. See Regan v. VOA Nat’l Housing, 61 W.C.D. 142 (W.C.C.A. 2000), summarily aff’d (Minn. Apr. 6, 2001); Land v. Washington Co. Sheriff’s Dep’t, slip op. (W.C.C.A. Dec. 23, 2003); Rothwell v. Minn. Dep't of Natural Resources, slip op. (W.C.C.A. Dec. 6, 1993); Braun v. St. John's Univ., slip op. (W.C.C.A. July 20, 1992). The absence of a reference to evidence does not mean that the evidence was not considered. It is sufficient that the findings decide all questions of law and fact submitted, and that substantial evidence in the record supports the compensation judge’s conclusion. Cochran v. Target Stores, No. WC16-6013 (W.C.C.A. Jun. 5, 2017).

In this matter, the issue of causation is explicitly addressed by well-founded medical opinion. In addition, the employee’s testimony is clear that he had neck pain which never resolved following the 1979 and 1984 work injuries. (T. 23-26, 31.) The self-insured employer contended that the employee suffered no injury to his neck. (T. 13.) As this court stated in Rasmussen v. Carl Bolander & Sons Constr., slip op. (W.C.C.A. Aug. 7, 1996), in reference to reliance on the employee’s testimony to support a determination of causation:

More recently, in Oleson v. Indep. Sch. Dist. #272 Eden Prairie Sch., 77 W.C.D. 573 (W.C.C.A. 2017), this court stated:

While the treating physician deferred an opinion on causation to “other providers,” the compensation judge may rely on other evidence in the record to reach a decision. The well-founded independent medical opinion and the employee’s credible testimony constitute substantial evidence.

The compensation judge found that the employee’s claimed treatment of the was reasonable and necessary and awarded payment or reimbursement. The 1979 and 1984 work injuries were admitted by the self-insured employer. This court has previously held that an implied finding regarding causation is sufficient. Guzman v. Registry Hotel, slip op. (W.C.C.A. Apr. 20, 1994), summarily aff’d (Minn. July 28, 1994); Ziehl v. Vreeman Constr. Co., slip op. (W.C.C.A. Oct. 15, 1991). As the evidence in this matter supports the award of the compensation judge, the decision is affirmed.