ADJ15225348 — California WCAB decision

What the panel ordered

Petition for Reconsideration denied; Almaraz/Guzman rating upheld as substantial medical evidence; permanent disability rating affirmed at 74%.

Petition for Reconsideration filed by defendant challenging the substantiality of the Almaraz/Guzman rating; WCJ decision and report adopted and reconsideration denied.

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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.

Permanent disability ratingApplicant prevailedright shoulder

The WCJ properly relied on Dr. Hindocha's Almaraz/Guzman rating as substantial medical evidence because it was based on reasonable medical probability, supported by specific findings including significant limitations in 7/8 ADL categories, unsuccessful surgeries, and muscle atrophy, and was consistent with applicant's testimony and medical records.

From the decision · page 1For the reasons stated in the WCJ's report, we agree that the opinions of panel qualified medical examiner (PQME) Rommel Hindocha is substantial medical evidence upon which the WCJ properly relied. To be considered substantial evidence, a medical opinion "must be predicated on reasonable medical probability." (E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408, 413, 416§ 17, 419 [33 Cal.Comp.Cases 660].) A physician's report must also 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

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Dr. Hindocha found significant limitations in 7 out of 8 activities of daily living (ADLs) for the applicant's right shoulder.

Favours Applicant prevailed

This supported the use of the Almaraz/Guzman rating over the strict AMA Guides rating as it more accurately reflected the applicant's disability.

From the decision · page 5The patient reports significant limitations in 7 /8 ADL categories. The patient is severely limited in his ADL's, with respect to his right upper extremity. The patient had the following relevant surgical procedures: right-sided supraspinatus, right-sided infraspinatus and right-sided subscapularis repair and a revision surgery for his right- sided subscapularis. The patient's supraspinatus and infraspinatus muscles arc atrophied. Evidently, the revision surgery was not successful and the patient's subscapularis remains tom, retracted and non-functional. The patient underwent a distal clavicle resection and acromial arthroplasty with respect to his right acromioclavicular joint.

The applicant underwent multiple surgeries including unsuccessful revision surgery and had muscle atrophy in the right shoulder.

Favours Applicant prevailed

These clinical findings justified the departure from the strict AMA Guides rating and supported the alternative Almaraz/Guzman rating.

From the decision · page 5The patient reports significant limitations in 7 /8 ADL categories. The patient is severely limited in his ADL's, with respect to his right upper extremity. The patient had the following relevant surgical procedures: right-sided supraspinatus, right-sided infraspinatus and right-sided subscapularis repair and a revision surgery for his right- sided subscapularis. The patient's supraspinatus and infraspinatus muscles arc atrophied. Evidently, the revision surgery was not successful and the patient's subscapularis remains tom, retracted and non-functional. The patient underwent a distal clavicle resection and acromial arthroplasty with respect to his right acromioclavicular joint.

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922

To be substantial medical evidence, a medical opinion must be predicated on reasonable medical probability, not speculative, based on pertinent facts and adequate examination, and set forth reasoning in support of conclusions.

The WCJ properly relied on Dr. Hindocha's opinion as substantial medical evidence because it met these criteria.

From the decision · page 1For the reasons stated in the WCJ's report, we agree that the opinions of panel qualified medical examiner (PQME) Rommel Hindocha is substantial medical evidence upon which the WCJ properly relied. To be considered substantial evidence, a medical opinion "must be predicated on reasonable medical probability." (E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408, 413, 416§ 17, 419 [33 Cal.Comp.Cases 660].) A physician's report must also 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

Milpitas Unified School District v. Workers' Comp. Appeals Bd. (Guzman III) (2010) 187 Cal. App. 4th 808

The AMA Guides are not to be literally and mechanically applied; physicians may use clinical judgment to provide a rating within the four corners of the Guides that more accurately reflects impairment.

Dr. Hindocha's use of the Almaraz/Guzman rating method was consistent with this standard, providing an alternative rating with explanation.

From the decision · page 7Pursuant to section 4660.1(d), the scheduled rating is prima facie evidence of an employee's permanent disability. However, the scheduled rating is rebuttable. (See Almaraz- Guzman III, supra, at pp. 852-853.) Specifically, the WPI portion of the scheduled rating may be rebutted by showing that "a different chapter, table, or method of assessing impairment of the AMA Guides more accurately reflects the injured employee's impairment than the chapter, table, or method used by the physician being challenged." (Almaraz-Guzman II, supra, at p. 1106.) Physicians must still evaluate permanent impairment while staying within the "four corners of the Guides" pursuant to the Labor Code. (Id. at p. 1101.)

ADJ15225348 · December 12, 2023

What the panel ordered

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