What the panel ordered
The Board rescinded the prior Findings and Order and substituted findings deferring issues of preexisting coronary heart disease disability, subsequent permanent disability of 35% or more, and combined disability of 70% or more; it found preexisting permanent disability from obstructive sleep apnea of 7%; and returned the matter to the trial level for further proceedings.
Applicant sought reconsideration of the Joint Findings and Order issued on November 23, 2022, which denied SIBTF benefits; the WCJ had found injury and permanent disability in one case but denied benefits and found no injury in the other; the WCJ recommended denial of the petition for reconsideration; the Board granted reconsideration to study factual and legal issues further.
What was disputed, and how it came out
Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.
The record required further development to determine if combined disability met the 70% threshold.
From the decision · page 17We are therefore persuaded that the record requires further development on the issue of whether applicant's combined preexisting and subsequent permanent disability equals 70% or more.
The medical record was unclear and required further development to determine preexisting coronary heart disease permanent disability.
From the decision · page 14This suggests that applicant may also establish that he had preexisting permanent disability resulting from coronary artery disease. However, the medical record regarding whether he had such a preexisting permanent disability is unclear. Specifically, although Dr. Schmitz opined that applicant's subsequent injury in the form of hypertension resulted in permanent disability of 25%, he was unable to testify as to what impairment, if any, applicant had in 2014 after his heart stent placement surgery and temporary total disability. (Opinion on Decision, pp. 6-12.)
The parties stipulated to subsequent injury but the level of permanent disability was deferred for further proceedings.
From the decision · page 15As to the issue of whether applicant had subsequent permanent disability equal to 35% or more of the total disability, when considered alone and without regard to occupation or age, the parties stipulated that applicant sustained subsequent injury to the heart, psyche, neck, and bilateral upper extremities during the period ending June 13, 2019. (Minutes of Hearing, Order of Consolidation, and Summary of Evidence, September 21, 2022, p. 2:6-33.)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Medical record was unclear on preexisting coronary heart disease permanent disability, requiring further development.
Favours neutral
The Board deferred this issue for further proceedings due to lack of substantial evidence.
From the decision · page 14This suggests that applicant may also establish that he had preexisting permanent disability resulting from coronary artery disease. However, the medical record regarding whether he had such a preexisting permanent disability is unclear. Specifically, although Dr. Schmitz opined that applicant's subsequent injury in the form of hypertension resulted in permanent disability of 25%, he was unable to testify as to what impairment, if any, applicant had in 2014 after his heart stent placement surgery and temporary total disability. (Opinion on Decision, pp. 6-12.)
Parties stipulated applicant sustained subsequent injury to heart, psyche, neck, and bilateral upper extremities ending June 13, 2019.
Favours Applicant prevailed
This established the basis for further disability evaluation but deferred the disability rating.
From the decision · page 15As to the issue of whether applicant had subsequent permanent disability equal to 35% or more of the total disability, when considered alone and without regard to occupation or age, the parties stipulated that applicant sustained subsequent injury to the heart, psyche, neck, and bilateral upper extremities during the period ending June 13, 2019. (Minutes of Hearing, Order of Consolidation, and Summary of Evidence, September 21, 2022, p. 2:6-33.)
Dr. Anderson's medical opinions were conclusory and lacked explanation, failing to provide substantial evidence for permanent disability and apportionment.
Favours Defendant prevailed
The Board rejected these opinions, favoring further development of the record.
From the decision · page 9Nor does he address why his findings regarding apportionment to nonindustrial factors differ substantially from the opinions of the panel selected QME. In terms of his apportionment analysis, for each of the three cardiac diagnoses (congestive heart failure, hypertension, and coronary artery disease) he provides the same percentage for apportionment between industrial and nonindustrial factors. (Id. at 44.) His opinions regarding apportionment are conclusory, with no explanation for how he arrived at his apportionment findings.
Applicant had preexisting permanent disability from obstructive sleep apnea of 7%.
Favours Applicant prevailed
This finding was substituted for the prior order and supported further proceedings.
From the decision · page 18FINDINGS OF FACT (ADJ1287154) 1. applicant born _______, while employed during the period through June 13, 2019 as a clinical review technician, Occupational Group Number 111, at Palo Alto, California, by Stanford Hospital, sustained injury arising out of and in the course of employment to his heart, psyche, neck and bilateral upper extremities. 2. Applicant had preexisting permanent disability resulting from obstructive sleep apnea of 7%. 3. The issue of whether applicant had preexisting permanent disability resulting from coronary heart disease is deferred. 4. The issue of whether applicant had subsequent permanent disability equal to 35% or more of his total disability is deferred. 5. The issues of whether applicant's combined preexisting and subsequent permanent disability equals 70% or more, and, as appropriate, the amount of applicant's total disability, are deferred.
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Diagnosed cervicalgia and bilateral carpal tunnel syndrome; opined repetitive overuse caused bilateral carpal tunnel; cervical issues not work related; carpal tunnel not permanent and stationary; no impairment ratings given.
The panel selected QME did not provide permanent disability for bilateral carpal tunnel syndrome as it was not permanent and stationary.
From the decision · page 5Ronald Chaplin evaluated the applicant as an orthopedic panel selected Qualified Medical Examiner (QME) on October 21, 2020. The applicant was complaining of pain in his bilateral hands and wrists which radiated to his arms and neck. Under the history of the injury, Dr. Chaplin noted that the applicant performed data entry 8 to 14 hours a day for the past 20 years. He diagnosed the applicant with cervicalgia in the past and bilateral carpal tunnel syndrome. He opined that it was within a reasonable degree of medical probability that the applicant had repetitive overuse of the upper extremities which led to the development of bilateral carpal tunnel syndrome. He opined that the cervical issues were not work related. He did not believe the carpal tunnel was permanent and stationary, and no impairment ratings were given. (Joint Exhibit 101, Report of Ronald Chaplan, M.D. dated October 26, 2020, pages 2, 6, and 7.)
Diagnosed major depressive disorder predominantly caused by employment; condition not at maximum medical improvement.
The psychiatric QME diagnosed major depressive disorder related to employment but did not find condition at MMI.
From the decision · page 5Vladimir Bokarius evaluated the applicant as a psychiatric panel QME on September 20, 2020. In his history, he noted that the applicant worked for Stanford Health Care as a Clinical Reviewer from April 1983 through June 2020. In 2009, he was charged with handling all bariatric surgeries which doubled his workload and he worked more than 8 hours a day. In 2010 he was made an hourly employee, took a pay cut in salary, and lost over 2000 hours of accumulated paid time off. By 2012 the work regarding bariatric surgeries was distributed equally among his team. He developed heart problems and underwent cardiac surgery in 2013 and denied any further psychiatric symptomatology until 2018. In 2018 he was put in charge of pain clinic patients and supervised a new team of reviewers. He was allowed to work overtime and would work late to help patients, but in the second part of 2019, overtime became very strict.
Diagnosed hypertension, idiopathic cardiomyopathy, coronary artery disease, peripheral edema, obstructive sleep apnea, erectile dysfunction, emotional stress/depression/anxiety; hypertension caused/aggravated by work; cardiomyopathy and coronary artery disease aggravated by industrial hypertension; obstructive sleep apnea nonindustrial; recommended treatment for hypertension and heart conditions; erectile dysfunction aggravated by medication.
Provided detailed causation and apportionment opinions but was unable to clarify preexisting coronary heart disease permanent disability.
From the decision · page 5Applicant was evaluated by James Schmitz as an internal medicine/cardiovascular disease panel QME on September 17, 2020. The applicant was complaining of hypertension, coronary artery disease, idiopathic cardiomyopathy and peripheral edema. Dr. Schmitz noted that he was diagnosed with high blood pressure in approximately 1999, and was started on medication on August 27, 2001 but then stopped the medication on his own. On January 10, 2003, he was seen in follow-up following a minor motor vehicle accident with elevated blood pressure and medication
Provided different assessments and apportionment analyses for hypertension, cardiomyopathy, and coronary artery disease than Dr. Schmitz but without explanation; incorrectly applied AMA Guides for upper extremity permanent disability; opinions not substantial evidence.
The Board found Dr. Anderson's opinions conclusory and lacking explanation, thus not substantial evidence.
From the decision · page 9... The panel selected QME orthopedic QME, Dr. Chaplin, did not provide any permanent disability to the upper extremities for the bilateral carpal tunnel syndrome. The only report in evidence from Dr. Chaplin states that the bilateral carpal tunnel was not yet permanent and stationary. (Joint Exhibit 101, page 7.)... Dr. Anderson, in his November 16, 2021 report, provided a different assessment of the level of permanent disability for the applicant's hypertension, and coronary artery disease than that of the panel selected QME, Dr. Schmitz. (Joint Exhibit 106, pages 42 -43.) In addition, he provided a different apportionment analysis for those the hypertension, cardiomyopathy and coronary artery disease. However, even though he reviewed the reporting of Dr. Schmitz, Dr. Anderson does not provide any explanation as to why he provides a different level permanent disability than that of the QME.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Escobedo; Hegglin v. Workmen's Comp. Appeals Bd. (1971) 4 Cal. 3d 162
Medical opinion must be framed in terms of reasonable medical probability, not speculative, based on pertinent facts and adequate examination, and set forth reasoning in support of conclusions.
The Board rejected medical opinions that were speculative or conclusory, requiring substantial evidence for findings.
From the decision · page 13To constitute substantial evidence "... a medical opinion must be framed in terms of reasonable medical probability, it must not be speculative, it must be based on pertinent facts and on an adequate examination and history, and it must set forth reasoning in support of its conclusions." (Escobedo, supra.) "Medical opinion... fails to support the Board's findings if it is based on surmise, speculation, conjecture or guess." (Hegglin v. Workmen's Comp. Appeals Bd. (1971) 4 Cal. 3d 162, 169 [36 Cal.Comp.Cases 93, 97].)
What proof carried it
The evidence the panel weighed, by kind.
Dr. Anderson's opinions lacked explanation and were conclusory, failing to provide substantial evidence for permanent disability ratings and apportionment.
From the decision · page 9Nor does he address why his findings regarding apportionment to nonindustrial factors differ substantially from the opinions of the panel selected QME. In terms of his apportionment analysis, for each of the three cardiac diagnoses (congestive heart failure, hypertension, and coronary artery disease) he provides the same percentage for apportionment between industrial and nonindustrial factors. (Id. at 44.) His opinions regarding apportionment are conclusory, with no explanation for how he arrived at his apportionment findings.
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About this page
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