SAIF Corp. v. Carlos-Macias

325 P.3d 827, 262 Or. App. 629
CourtCourt of Appeals of Oregon
DecidedMay 7, 2014
Docket1004446, 1004555; A150950
StatusPublished
Cited by11 cases

This text of 325 P.3d 827 (SAIF Corp. v. Carlos-Macias) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
SAIF Corp. v. Carlos-Macias, 325 P.3d 827, 262 Or. App. 629 (Or. Ct. App. 2014).

Opinion

EGAN, J.

Employer Sherman Paint & Collision, and its workers’ compensation insurer SAIF Corporation (collectively, petitioners) seek judicial review of an order of the Workers’ Compensation Board (board), which determined that there was a causal relationship between requested diagnostic medical services and claimant’s accepted conditions sufficient to support the compensability of those diagnostic services under ORS 656.245(l)(a). Petitioners assert that the board erred when it upheld the denial of claimant’s current condition while simultaneously finding a sufficient causal relationship between the proposed diagnostic medical services and his previously accepted conditions to support the compensability of those services. Petitioners argue that the diagnostic services were not related to claimant’s “accepted condition” but were instead designed solely to rule out unrelated noncompensable conditions. Finally, petitioners argue that the board’s decision is not supported by substantial evidence or substantial reason. For the reasons that follow, we affirm.

The underlying claim dates from a work-related injury sustained when claimant damaged his left shoulder while lifting and dragging a heavy forklift component in November 2007. We begin by recounting the procedural history of this case before turning to the underlying medical history.

After SAIF issued an acceptance for a “left shoulder strain,” claimant made a demand for acceptance of additional conditions, namely, shoulder sprain, acromioclavicu-lar (AC) joint sprain, hypertrophic rotator cuff tendinosis, and AC joint impingement. In a modified notice of acceptance, SAIF took responsibility for the AC sprain in addition to the previously accepted left-shoulder strain and also eventually accepted the left-shoulder rotator cuff tendinosis.

SAIF issued a notice of closure in September 2009 that denied an award of permanent partial disability. The Workers’ Compensation Division of the Department of Consumer and Business Services (the division) reviewed that closure and concluded that claimant was medically stationary with regard to the “accepted condition(s)” and [632]*632allowed claim closure. The reviewer made a significant change to the notice of closure as it related to permanent partial disability by attributing 75 percent of claimant’s loss of range of motion and 50 percent of the loss of repetitious use of the shoulder to the “accepted condition(s).” The order on reconsideration awarded claimant a total of eight percent permanent partial disability to his left shoulder.

Turning now to the medical history, claimant sought initial medical treatment with Dr. Ackerman, who diagnosed a left-shoulder strain. By January 2008, Ackerman had expanded his diagnosis to include a left-shoulder strain and an AC strain. Claimant continued to work buffing cars and his pain began to radiate into the left upper arm. An MRI ordered by Ackerman identified swelling in the AC joint and evidence of rotator cuff tendinosis. Claimant saw an orthopedic surgeon, Dr. Straub, who diagnosed shoulder strain.

Following a July 2008 medical examination, Dr. Leadbetter opined that claimant suffered from a left-shoulder strain and sprain and hypertrophic rotator cuff tendinosis. Leadbetter declared claimant medically stationary without impairment. Ackerman issued a check-the-block concurrence letter.

Straub performed left-shoulder surgery in December 2008. His post-operative diagnosis included left-shoulder impingement, degenerative changes in the AC joint, and a superior labral tear from anterior to posterior (SLAP tear). Straub did not know why claimant’s left shoulder continued to be painful. A subsequent examination by Ackerman revealed some swelling around claimant’s left hand and arm. Concerned that there might be a vascular compromise secondary to the surgery, Ackerman referred claimant to an orthopedist.

The orthopedist, Dr. Fletcher, diagnosed AC joint pain and subacromial bursitis recalcitrant to treatment. He thought that the post-surgery symptoms arose largely because “the AC joint appears to not have been completely resected.” Fletcher discounted the possibility of vascular impairment; he thought that most of claimant’s pain centered [633]*633on the AC joint. He recommended diagnostic and possible therapeutic injections of lidocaine and a corticosteroid.

At claimant’s next examination with Ackerman, the physician diagnosed left-arm swelling and pain of unknown origin. A contemporaneous examination by Dr. Hurtado, claimant’s primary care physician, diagnosed “edema” in the left arm; Hurtado suspected injury to the lymphatic vessels and recommended a vascular evaluation.

SAIF referred claimant to a medical examination with Dr. Matteri, who opined that claimant’s symptoms were embellished and nonorganic. He stated that the accepted conditions were medically stationary and that none of those conditions contributed to any of claimant’s permanent disability.

After a vascular specialist ruled out any vascular disorder associated with the injury, claimant was referred to Dr. Lin, who recommended the diagnostic tests that are here in dispute. Specifically, Lin ordered “EMG/nerve conduction studies” (EMG test) to rule out a neurological component of claimant’s symptoms; he also recommended a triple-phase bone scan to rule out “complex regional pain syndrome type 1 versus reflex sympathetic dystrophy.”

After reviewing the EMG-test and triple-phase-bone-scan requests, Oregon Health Services (OHS), the managed care organization assigned to the claim, denied them. Claimant appealed to the medical director of the division. In response to a request from SAIF, Lin identified the requested procedures as “palliative”;1 in a different letter, he indicated that the requested tests were aimed at determining the “extent” of claimant’s injury. In a clinical note, Lin explained the need for the tests as follows:

“The triple-phase bone scan is needed to try to corroborate whether this patient has CRPS type 1/RSD. Although the patient’s pain behaviors make clinical interpretation [634]*634very difficult, as a result we have to rely on objective data. If the triple-phase bone scan is positive, it implies the diagnosis. If it is negative, it does not completely rule it out, but in this patient it would in my mind given his behaviors. * * * The same is true of the electrodiagnostic studies.”

SAIF sent the case back to Matteri for a “records review'.” He concluded that none of the requested tests was required medical “treatment for any accepted conditions resulting from his November 13, 2007 work incident.”

SAIF issued a current-condition denial; that denial listed the accepted conditions and explained that those conditions were “no longer a material contributing cause of [claimant’s] left [-] shoulder complaints and [the] need for treatment.” The denial also provided that claimant could continue to receive benefits for his “accepted conditions.”

SAIF and claimant solicited opinion letters from the doctors involved. Matteri issued a check-the-block opinion that the “triple phase bone scan” was not necessary to determine the “extent of the accepted conditions.” (Formatting omitted.) Matteri added that claimant did not suffer from “CRPS or RSD.” Straub issued a similar check-the-block letter, and Ackerman followed suit.

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Bluebook (online)
325 P.3d 827, 262 Or. App. 629, Counsel Stack Legal Research, https://law.counselstack.com/opinion/saif-corp-v-carlos-macias-orctapp-2014.