West Virginia Court Reverses Medical Findings of Board of Review
Acknowledging the broad latitude afforded the state’s Workers’ Compensation Board of Review when it comes to weighing the medical evidence before it, the Supreme Court of Appeals of West Virginia, in a memorandum opinion, nevertheless held that the Board’s decision was so clearly wrong that when all inferences were resolved in favor of the Board’s findings, reasoning and conclusions, there was still insufficient support to sustain the decision [West Va. Univ. v. Shaffer, 2020 W. Va. LEXIS 525 (July 9, 2020)].
Background
Shaffer, a trade specialist lead, injured his shoulders and lower back in the course of his employment on January 26, 2016, when he tripped and fell. He was initially seen by Dr. Bailey on April 8, 2016. Shoulder x-rays taken on April 11, 2016, showed mild degenerative changes. Lumbar x-rays showed mild scoliosis with advanced degenerative disc changes and facet arthrosis. Shaffer reported that he did not seek medical treatment for the January injury until April 8, 2016, because he was treating himself at home with over the counter medication. Dr. Bailey diagnosed lumbar and bilateral shoulder sprains and recommended MRIs.
Shaffer had a history of lower back and bilateral shoulder problems. On November 7, 2003, he sought treatment at Uniontown Hospital for right shoulder pain that started after he accidentally pulled down a piece of equipment on himself. X-rays of the lumbar spine showed degenerative changes, mostly at L4-5 and L5-S1. A right shoulder MRI performed on December 3, 2003 revealed degenerative joint disease of the acromioclavicular joint with impingement on the rotator cuff causing rotator cuff tendonitis. A left shoulder MRI showed degenerative joint disease. A lumbar MRI showed cord compression due to a herniated T11-12 disc.
A right shoulder MRI performed on August 23, 2016, showed a full thickness tendon tear with retraction as well as some tendinosis. A left shoulder MRI showed a full thickness tear, joint osteoarthritis, and cartilage thinning.
There followed a complicated attempt to resolve the legal issues regarding Shaffer’s claim. In relevant part, the Office of Judges concluded that Shaffer failed to show that he remained temporarily and totally disabled due to his compensable injury. The Board reversed, in part and remanded the claim.
Eventually, the Office of Judges determined that although Shaffer clearly had preexisting degenerative joint disease in both shoulders, as seen on 2003 MRIs, those MRIs showed no evidence of tearing. MRIs taken after the compensable injury showed tears in both rotator cuffs. The Office of Judges further found that Shaffer received some treatment for his shoulders in 2003, but had no treatment in the ten years preceding the compensable injury. The Office of Judges concluded that if Shaffer had massive bilateral rotator cuff tears due to degeneration, it would be reasonable to expect some treatment during this time. Further, he was fully capable of performing his job duties prior to the compensable injury, after which he was unable to perform his job duties. The Board of Review adopted the findings and conclusions of the Office of Judges and affirmed its October 30, 2018 Order that held the claim compensable for bilateral rotator cuff tears.
Supreme Court’s Decision
The Court indicated the medical evidence clearly showed that Shaffer had bilateral shoulder degenerative changes several years before the compensable injury occurred, that a December 2003 MRI showed degenerative joint disease with impingement of the rotator cuff causing tendonitis in the right shoulder, and that the left shoulder showed degenerative joint disease. The Court observed that treatment notes by Dr. Netaji from December 2003 through April 2005 showed Shaffer had rotator cuff tendonitis on the left and degenerative joint disease and impingement on the right. Another physician, Dr. Grady, stated in his February 13, 2018, record review that those conditions indicated a predisposition to degenerative rotator cuff tears.
The Court further observed that Shaffer’s primary physician, Dr. Bailey, was the only physician of record to opine that the compensable injury resulted in bilateral rotator cuff tears. In his deposition, however, Dr. Bailey stated it was very difficult for him to determine if the rotator cuff tears were the result of degeneration or trauma. He testified further that he usually referred patients to a specialist to make that determination.
Analyzing the medical testimony and reports, the Court observed that Dr. Agnew, an orthopedic surgeon, performed an independent medical evaluation of Shaffer and found that the compensable injury resulted in bilateral shoulder strains. He found that Mr. Shaffer had chronic degenerative changes throughout both shoulders as well as massive rotator cuff tears that were consistent with arthropathy. While the doctor found 17.5 percent shoulder impairment, he apportioned the entire amount to preexisting, degenerative rotator cuff pathology. Another physician, Dr. Thaxton, performed a physician review on July 10, 2017, and also found that the bilateral rotator cuff tears were degenerative and unrelated to the compensable injury. Lastly, Dr. Grady, mentioned above, performed a record review on February 13, 2018. He too determined that Shaffer’s preexisting degenerative changes and bilateral rotator cuff tears were not related to the compensable injury. He opined that the 2003 MRIs showed preexisting degenerative change with impingement, which indicated a predisposition to degenerative rotator cuff tears.
In the face of all this medical evidence, there was insufficient support for the Board’s findings. The matter was remanded for reinstatement of the claims administrator’s decisions, which had denied additional benefits.