Hutchings v. Labor Commission ( 2016 )

2016 UT App 160THE UTAH COURT OF APPEALS
KAYLA HUTCHINGS,
Petitioner,
v.
LABOR COMMISSION AND WASHINGTON
COUNTY SCHOOL DISTRICT,
Respondents.
Opinion
No. 20150429-CA
Filed July 29, 2016
Original Proceeding in this Court
Robert M. Jensen and Virginius Dabney, Attorneys
for Petitioner
Bret A. Gardner and Kristy L. Bertelsen, Attorneys
for Respondent Washington County School District
JUDGE STEPHEN L. ROTH authored this Opinion, in which JUDGE
GREGORY K. ORME concurred. SENIOR JUDGE RUSSELL W. BENCH
concurred in the result. 1
ROTH, Judge:
¶1 Kayla Hutchings seeks review of the Labor Commission’s
(the Commission) decision to deny her claim for permanent total
disability. We decline to disturb the Commission’s decision.
1. Senior Judge Russell W. Bench sat by special assignment as
authorized by law. See generally Utah R. Jud. Admin. 11-201(6).
Hutchings v. Labor Commission
BACKGROUND
¶2 In August 2008, Hutchings was employed by the
Washington County School District as a cafeteria worker. One
day in late August, she and a coworker were loading boxes of
food into the school’s walk-in freezer. After continuously lifting
and loading boxes that weighed up to forty pounds for about
half an hour, Hutchings and her coworker had to lift a box that
weighed approximately eighty pounds onto a shelf in the
freezer. When Hutchings pushed the box onto the shelf, she
experienced a sudden pain in her back and immediately felt sick
to her stomach. Subsequently, Hutchings refrained from tasks
that required her to bend and lift.
¶3 Hutchings, however, did not miss any work due to the
incident, and she did not immediately seek medical attention for
pain that may have resulted from it. Nor did she mention the
incident or any back or leg pain during a November 2008
appointment with Dr. Britt, a WorkMed physician, regarding
another accident she also suffered while at work—a steam burn
on her arm. Instead, Hutchings first reported to a medical
professional that she was suffering from low back or radicular
leg pain in December 2008 during the course of an annual visit to
her primary care physician, Dr. Staheli. Dr. Staheli ordered an
MRI of her lumbar spine, which showed that Hutchings suffered
from degenerative disc disease on multiple spinal levels as well
as other degenerative phenomena in her lower back.
¶4 Shortly after the MRI was completed, the school’s
principal referred Hutchings to WorkMed for her low back and
leg pain. At this second WorkMed appointment, Dr. Britt noted
that Hutchings reported “[n]o specific trauma” but indicated
that at the first of the school year there was always heavy lifting
required; he also noted that Hutchings’s pain began around that
time and that her pain had “to be work related.” He indicated
that the pain had worsened within the four weeks preceding the
appointment and that she had had no medical treatment for the
20150429-CA 2 2016 UT App 160Hutchings v. Labor Commission
problem until her December appointment with Dr. Staheli.
Dr. Britt diagnosed Hutchings with lower back pain and a disc
extrusion. He referred Hutchings to Dr. Snook, a neurosurgeon,
but he otherwise released her back to work with modified duty.
¶5 Dr. Snook diagnosed Hutchings with degenerative disc
disease as well as nerve-root compression from a cyst in her
lower back. In February 2009, he performed surgery to
decompress the affected nerve root. He noted that while there
had been “some suggestion” prior to surgery that a herniated
disc in Hutchings’s lower back was also compressing the nerve
root, during surgery he found the disc at issue to be “flat,” with
no sign that it was compressing on the nerve root. Consequently,
he performed no disc surgery.
¶6 While the surgery initially alleviated Hutchings’s pain,
by June 2009, Hutchings had again seen both Dr. Staheli and
Dr. Snook, complaining that her leg and back pain had returned.
From this point forward, Hutchings continued to experience
lower back and radicular leg pain and she tried many
treatments, including epidural shots and electrotherapy. In May
2012, she sought another opinion by Dr. Major, who diagnosed
her with a degenerative vertebral condition and joint disease in
her lower back, though he was uncertain regarding the exact
source of her pain. He opined that Hutchings needed a “2-level
spinal fusion” to relieve her symptoms.
¶7 In January 2012, Hutchings filed an application for a
hearing with the Commission to determine whether she was
entitled to disability compensation due to the accident that
occurred at the end of August 2008. After an evidentiary
hearing, the administrative law judge (the ALJ) determined in an
August 2013 decision that at the time of her accident, Hutchings
had been suffering from a preexisting degenerative back
condition. The ALJ noted that because of the preexisting
condition, Hutchings was required to show not just that the
injury “ar[ose] out of and in the course of [her] employment,”
20150429-CA 3 2016 UT App 160Hutchings v. Labor Commission
see Utah Code Ann. § 34A-2-410 (LexisNexis 2015), but “that the
work exertion at the time of the accident was unusual or
extraordinary as compared to the exertions of nonemployment
life,” see Allen v. Industrial Comm’n, 729 P.2d 15, 26 (Utah 1986)
(“[W]here the claimant suffers from a preexisting condition
which contributes to the injury, an unusual or extraordinary
exertion is required to prove legal causation.”). The ALJ then
concluded that Hutchings’s exertion was not unusual under the
circumstances, and as a result, Hutchings had failed to establish
legal causation.
¶8 Hutchings sought review by the Commission of the ALJ’s
order denying her benefits. The Commission determined that
“[w]hile there is evidence of pre-existing degenerative changes
in Ms. Hutchings’s lumbar spine, the record does not clearly
show that she suffered from a pre-existing condition that
contributed to her work injury.” It therefore concluded that,
contrary to the ALJ’s determination, “the more stringent
standard of legal causation does not apply to Ms. Hutchings’s
claim.” Instead, the Commission determined that under the less
stringent standard, legal causation was established by the
evidence before the ALJ. The Commission then decided that
there was a conflict in the medical opinions over whether her
work accident was the medical cause of her “current low-back
condition” and that the issue of medical causation should be
referred to a medical panel. Accordingly, the Commission set
aside the ALJ’s order and remanded the case “for consideration
of the medical cause of Ms. Hutchings’s current low-back
problems with the participation of an impartial medical panel
qualified to assess her condition.”
¶9 The ALJ then instructed the medical panel that it was to
answer three related questions:
Is there any medically demonstrable causal
connection between [Hutchings’s] low back
20150429-CA 4 2016 UT App 160Hutchings v. Labor Commission
condition and the industrial accident which
occurred in August 2008?
Please state the percentage of whole person
impairment, if any, sustained by [Hutchings] as a
result of the medical problem caused by the
industrial accident.
Please identify any medical or functional capacity
limitations which apply to [Hutchings] and
specifically indicate[] whether the limitation is a
result of injury sustained in the August 2008
industrial accident.
The medical panel ultimately concluded that there was no
medically demonstrable causal connection between the August
2008 accident and Hutchings’s low back condition, and as a
consequence, the accident itself did not result in any impairment
or cause any “functional capacity limitations.”
¶10 The panel reasoned that Hutchings’s history of “four
medical encounters for low back pain . . . beginning 20 months
before the alleged injury,” with the last one “only 20 days prior”
to the event itself, indicated “significant lumbar degenerative
pathology.” Thus, it concluded that, when this chronological
history was combined with the results of the December 2008
MRI (which showed significant degenerative conditions “at four
levels” of the spine), “it is clear that Mrs. Hutchings’[s] low back
condition antedated” the August 2008 industrial accident.
¶11 The panel then explained that “[o]ther historical
information” post-dating the August 2008 accident also
supported its conclusion. For example, the panel noted, (1) in
November 2008, about three months after the accident,
Hutchings “was examined and treated by Dr. Britt at WorkMed”
for an unrelated workplace injury, but there was “no
information relative to [low back or leg pain] recorded during
20150429-CA 5 2016 UT App 160Hutchings v. Labor Commission
that visit,” and she was “released . . . to regular duty” less than a
week later; (2) Hutchings “missed work due to headache[s] since
the start of the school year but never from [low back pain] or leg
pain”; (3) there was no mention of the August 2008 accident in
Dr. Staheli’s report of Hutchings’s December 2008 annual
physical, despite the fact that she complained of low back pain
and Dr. Staheli ordered an MRI; and (4) while Dr. Britt recorded
in his report of her December 16, 2008, visit to WorkMed that
Hutchings “had noted [low back]/leg pain since restarting
school,” Dr. Britt also recorded that “there was ‘no specific
trauma’” that explained her symptoms but instead only “a lot of
heavy lifting at the ‘first of the year.’” The medical panel noted
that it found Dr. Snook’s surgical findings to be “of interest”
where Dr. Snook performed “[n]o disc surgery” because he
found a “flat (not bulging) . . . disc with no evidence of
encroachment” on the nerve root in Hutchings’s lower back that
he had earlier diagnosed as compressed and where he did not
see the cyst that he considered to be the cause of the nerve-root
compression.
¶12 The panel ultimately concluded that “[t]he [medical
record] information cited in this comment does not allow the
medical panel to find any reasonable demonstrable causal
connection between Mrs. Hutchings[’s] low back condition and
the industrial accident which occurred in August 2008.” As a
result, the panel also determined that there was no whole-person
impairment attributable to the accident and that, although
Hutchings had capacity limitations of “Sedentary Physical
Demand Characteristic of Work Level,” “this is not related to the
August 2008 industrial accident.”
¶13 Hutchings objected to the medical panel report, but the
ALJ found “no basis to require a hearing or disallow the medical
panel report” and admitted it into the record. The ALJ then
found that the “medical panel opinion [was] persuasive given
the [medical panel’s] expertise, independence and sound
analysis” and that she had “reviewed the medical record and
20150429-CA 6 2016 UT App 160Hutchings v. Labor Commission
[found] the panel’s analysis consistent with the record and
supported by the opinion of Dr. Knoebel.” 2 The ALJ determined
that “[t]he weight of the evidence presented does not support
the Petitioner’s position” and concluded that Hutchings had
“failed to meet her burden of proof regarding medical
causation.”
¶14 The Commission affirmed the ALJ’s decision and denied
Hutchings’s request for reconsideration. Hutchings seeks review
of these orders.
ISSUES ON APPEAL
¶15 This case concerns medical causation. Hutchings’s central
claim on appeal is that the Commission’s medical causation
determination was erroneous. She contends that it was error for
the Commission to adopt the medical panel report because the
medical panel did not properly apply the medical causation test.
In particular, Hutchings asserts that the medical panel failed to
consider whether the accident medically caused or aggravated
her preexisting low back condition. Instead, she contends, the
medical panel “considered only preexisting conditions” as a
medical cause and then “stopped” the analysis without
considering “the accident as a cause.” She also contends that the
evidence does not support the medical panel’s and the
Commission’s determination that the accident did not cause or
aggravate her low back condition.
2. Dr. Knoebel was the independent medical evaluator who
examined Hutchings in May 2012, after she had filed her
application for a hearing for disability benefits. He ultimately
concluded that her low back condition was degenerative and
“[n]on-industrial.”
20150429-CA 7 2016 UT App 160Hutchings v. Labor Commission
ANALYSIS
I. Applicable Law
¶16 Under our Workers’ Compensation Act, industrial
accidents that aggravate or “light up” a preexisting condition are
compensable. See, e.g., Nyrehn v. Industrial Comm’n, 800 P.2d 330,
335 (Utah Ct. App. 1990). In order to qualify for compensation,
the claimant must demonstrate (1) that the injury occurred “by
accident” 3 and (2) that the conditions and activities of the job
were the cause of the injury. See Allen v. Industrial Comm’n, 729
P.2d 15, 18 (Utah 1986); see also Utah Code Ann. § 34A-2-401
(LexisNexis 2015). The key causation question is “whether, given
this body and this exertion, the exertion in fact contributed to the
injury.” Allen, 729 P.2d at 24. The answer to this question has
two components. The claimant must show that the work exertion
was both the legal cause and the medical cause of the injury or
disability. See id. at 25–27.
¶17 The purpose of legal causation is to determine “what kind
of exertion satisfies the test of ‘arising out of the employment’”
by examining the work-related exertion that led to the injury in
relation to any “‘personal causal contribution’” of the claimant—
usually an existing physical condition. Id. at 25–26 (emphasis
added) (citations omitted). The employer bears the burden of
demonstrating the existence of a preexisting condition and that
the condition contributed to the injury. Nyrehn, 800 P.2d at 334. If
the employer does so, “a claimant with a preexisting condition
must show that the employment contributed something
substantial to increase the risk he already faced in everyday life
because of his condition.” Allen, 729 P.2d at 26. Thus, “where the
claimant suffers from a preexisting condition which contributes
to the injury, an unusual or extraordinary exertion is required to
3. Neither party contests that Hutchings’s injury occurred “by
accident.”
20150429-CA 8 2016 UT App 160Hutchings v. Labor Commission
prove legal causation,” with the “extra exertion serv[ing] to
offset the preexisting condition of the employee as a likely cause
of the injury.” Id. at 25–26. In contrast, “[w]here there is no
preexisting condition, a usual or ordinary exertion is sufficient
[to establish legal causation].” Id. at 26.
¶18 The determination of medical causation may also take
into account the role of a preexisting condition in the claimed
disability. See, e.g., Giesbrecht v. Board of Review, 828 P.2d 544, 547
(Utah Ct. App. 1992) (upholding the Industrial Commission’s
denial of benefits when the preexisting condition (cancer) was
not aggravated by the injury claimed in the case (a bone fracture
in the claimant’s leg)); Virgin v. Board of Review, 803 P.2d 1284,
1287–90 (Utah Ct. App. 1990) (upholding the Industrial
Commission’s decision to deny benefits where the claimant’s
preexisting condition was the “sole [medical] cause” of the
claimant’s disability); Olsen v. Industrial Comm’n, 776 P.2d 937,
939–40 (Utah Ct. App. 1989) (declining to disturb the Industrial
Commission’s adoption of the medical panel’s conclusion that
claimant’s condition was caused by preexisting heart disease),
aff’d, 797 P.2d 1098 (Utah 1990); Large v. Industrial Comm’n, 758
P.2d 954, 957 (Utah Ct. App. 1988) (declining to disturb the
Industrial Commission’s causation determination where
substantial evidence supporting the determination that
preexisting conditions, not the claimant’s injury, was “the
medical cause of [the claimant’s] permanent total disability
status”). The purpose of the medical causation requirement “is to
ensure that there is a medically demonstrable causal link
between the [legally sufficient] work-related exertions and the
unexpected injuries that resulted from those strains.” Allen, 729
P.2d at 27; see also Nyrehn, 800 P.2d at 334 (“Under the legal
[causation] test, the law must define what kind of exertion
satisfies the test of ‘arising out of the employment’ . . . [then] the
doctors must say whether the exertion (having been held legally
sufficient to support compensation) in fact caused this [injury].”
(omission and second and third alterations in original) (citation
20150429-CA 9 2016 UT App 160Hutchings v. Labor Commission
and additional internal quotation marks omitted)). To meet the
medical causation requirement, the claimant must “prove the
disability is medically the result of an exertion or injury that
occurred during a work-related activity” by showing through
“evidence, opinion, or otherwise that the stress, strain, or
exertion required by his or her occupation led to the resulting
injury or disability.” Allen, 729 P.2d at 27; accord Cook v. Labor
Comm’n, 2013 UT App 286, ¶ 12, 317 P.3d 464. In this regard, a
claimant attempting to show that the work-related exertion
aggravated a preexisting condition “must prove the subsequent
disability is medically the result of an exertion or injury that
occurred during a work-related activity, and not solely the result
of a pre-existing condition.” Virgin, 803 P.2d at 1288 (citation and
internal quotation marks omitted). If the claimant cannot do so,
then “compensation should be denied.” Allen, 729 P.2d at 27.
Furthermore, because medical causation is often dependent
upon interpretation of relevant medical records and specialized
examination of the claimant, our supreme court has observed
that “[i]t is through the expertise of the medical panel that the
[Industrial] Commission should be able to make the
determination of whether the injury sustained by a claimant is
causally connected or contributed to by the claimant’s
employment.” Id. (citation and internal quotation marks
omitted).
¶19 In Virgin v. Board of Review, 803 P.2d 1284 (Utah Ct. App.
1990), the claimant suffered an industrial accident where he was
hit by a piece of equipment on his left hip and knocked down. Id.
at 1285. Three days after the accident, he was examined by a
physician’s assistant who only “found bruising and tenderness
in the left hip area, but no fractures.” Id. The claimant “made no
claim for compensation at that time and did not miss any work
as a result of” the accident. Id. About twenty months later, the
claimant underwent a total hip replacement and submitted a
claim for medical expenses and disability related to the surgery,
“claiming his hip replacement surgery was caused in part by his
20150429-CA 10 2016 UT App 160Hutchings v. Labor Commission
. . . industrial accident.” Id. at 1286. The medical panel explained
that “perhaps the surgery happened sooner than it would have
without the industrial accident,” but it ultimately concluded that
the claimant’s need for hip surgery and subsequent disability
“were not caused by the industrial injury.” Id. at 1289. We
upheld the Industrial Commission’s decision to deny benefits
because the medical evidence permitted only speculation that
the accident hastened the surgery and there was no other
evidence that the claimed impairment was attributable to the
industrial accident. Id. at 1289–90. Rather, there was substantial
evidence supporting the Industrial Commission’s determination
that a medical condition that both predated and had no relation
to the accident necessitated the hip replacement. Id. Thus, the
disability for which the claimant sought compensation—his hip
replacement—was not the medical result of the workplace
accident because the claimant “would have needed the surgery
in any event” due to his preexisting condition. Id. Accordingly,
the claimant failed to demonstrate that his hip replacement was
attributable to the industrial accident. Id.
¶20 In sum, the role of a preexisting condition in the
determination of legal causation is different from the role such a
condition plays in the determination of medical causation. Once
a preexisting condition is identified, the legal causation question
depends on whether the work-related exertion was no more than
the physical stresses encountered in ordinary life. Medical
causation, then, depends on whether a preexisting condition
actually caused or aggravated the specific injury or disability for
which compensation is sought.
¶21 Here, Hutchings sought compensation for the economic
consequences of her current low back condition. To be entitled to
compensation, she was therefore required to demonstrate by a
preponderance of the evidence that the conditions and activities
she experienced at work in August 2008 were both the legal and
the medical cause of her current low back condition. The
Commission determined that she met the test for legal causation
20150429-CA 11 2016 UT App 160Hutchings v. Labor Commission
because the accident was of a kind that could result in
compensable injury for her back problems even in the face of a
potentially related preexisting condition, and Hutchings does
not challenge that determination on appeal. Thus, Hutchings
must now demonstrate that the Commission’s conclusion that
she had not established medical causation—that the accident
caused or aggravated the specific disability for which she seeks
compensation (her low back condition)—was based on an
incorrect legal premise or that it was not supported by
substantial evidence in the record. See Oliver v. Labor Comm’n,
2015 UT App 225, ¶ 8, 359 P.3d 684 (explaining that we review
“the Commission’s application and interpretation of law for
correctness” and that “we will not disturb factual findings unless
[the petitioner] demonstrates that a finding is not supported by
substantial evidence”), cert. granted, 366 P.3d 1213 (Utah Oct. 27,
2015) (No. 20150889). Hutchings has effectively conceded that
she was suffering from a degenerative spinal condition at the
time of her accident by arguing that the accident aggravated this
condition. Thus, in order to demonstrate medical causation, she
must show that the Commission erred in concluding that
preexisting degenerative changes were the sole medical cause of
her current low back condition. See Virgin, 803 P.2d at 1288.
II. The Determination of Medical Causation in the Present Case
¶22 Hutchings argues that the medical panel failed to
properly analyze medical causation and that the Commission’s
subsequent adoption of the report perpetuated the error. She
contends that it is clear the medical panel considered only her
preexisting condition as a medical cause of her disability and did
not consider whether the accident aggravated or contributed to
the conditions for which she seeks compensation. As proof, she
points to the instructions given to the medical panel, the medical
panel’s reasoning, and certain medical evidence.
¶23 Medical causation is fundamentally a factual
determination. See Chase v. Industrial Comm’n, 872 P.2d 475, 479
20150429-CA 12 2016 UT App 160Hutchings v. Labor Commission
(Utah Ct. App. 1994). “We will not disturb the Commission’s
factual findings unless the party challenging the findings
demonstrates that a finding is not supported by substantial
evidence.” Swift Transp. v. Labor Comm’n, 2014 UT App 104, ¶ 8,
326 P.3d 678. The Commission is the ultimate finder of fact, even
if “a medical panel is convened.” Danny’s Drywall v. Labor
Comm’n, 2014 UT App 277, ¶ 14, 339 P.3d 624 (explaining that
“[t]he role of the Medical Panel is to evaluat[e] medical evidence
and advis[e] an administrative law judge with respect to the
administrative law judge’s ultimate fact-finding responsibility”
but that the Commission “is always the ultimate fact finder” and
“is not bound by the panel’s report” (alterations in original)
(citations and internal quotation marks omitted)). The
Commission is neither bound to adopt the medical panel’s
report, nor is it obligated to base its findings and decisions on
the report. Id. And while “[i]t is not unusual for . . . the
Commission to adopt the findings of a medical panel,” the
Commission’s “prerogative and duty . . . [is] to consider not only
the report of the medical panel, but also all of the other evidence
and to draw whatever inferences and deductions fairly and
reasonably could be derived therefrom.” Id. (first alteration in
original) (citations and internal quotation marks omitted).
Indeed, the Utah Supreme Court has stated that the medical
panel’s “proper purpose is limited to medical examination and
diagnosis, the evidence of which is to be considered by the
[Industrial] Commission in arriving at its decision.” Jensen v.
United States Fuel Co., 424 P.2d 440, 442 (Utah 1967).
¶24 However, whether the Commission has applied the
correct legal standard in reaching its medical causation finding is
a legal question, which we review for correctness. See Provo City
v. Labor Comm’n, 2015 UT 32, ¶ 17, 345 P.3d 1242 (stating that
“[f]or appeals from administrative decisions,” “we review the
law applied to [the] facts for correctness”). As discussed below,
we conclude that both the medical panel and the Commission
20150429-CA 13 2016 UT App 160Hutchings v. Labor Commission
properly considered whether the industrial accident aggravated
Hutchings’s preexisting condition.
A. The ALJ’s Instructions to the Medical Panel
¶25 Hutchings claims that the medical panel was improperly
instructed regarding the medical causation test, and, in
particular, that the Commission failed to ensure that the medical
panel was aware of and applied the aggravation rule. Medical
panel instructions generally do not provide a basis for an
appellate court to disturb the Commission’s findings. See
Johnston v. Labor Comm’n, 2013 UT App 179, ¶¶ 23–25, 307 P.3d
615. In Johnston, the claimant argued the same legal error that
Hutchings argues here—that the medical panel was not aware of
the aggravation rule and instead “employed some other method
for determining medical causation.” Id. ¶ 24. However, we
concluded in Johnston that the medical panel’s “understanding of
the aggravation rule is not binding on the [Commission]”
because the Commission, not the medical panel, makes the
ultimate medical causation determination. Id. We observed that
“medical panels [are] comprised of individuals without legal
training” and that the “medical panel . . . is not the finder of fact
and does not make a final and binding [legal] determination.” Id.
Rather, the Commission is the ultimate fact finder, and it is “not
bound by the opinions contained in the medical panel’s report.”
Id. ¶ 23. As a result, we reasoned that even if the medical panel
was unaware of the legal rules related to medical causation or
“employed some other method for determining medical
causation,” that would not provide a basis for convening a
hearing regarding the medical panel report or for disturbing the
Commission’s factual findings. See id. ¶¶ 23–25. It was therefore
not an error for the Commission to decline the petitioner’s
request to hold a hearing to inquire into the medical panel’s
understanding of the aggravation rule. Id. ¶ 25. Likewise, even
assuming that Hutchings is correct that the medical panel was
incorrectly instructed regarding the medical causation test, “the
medical panel’s possible misunderstanding of the aggravation
20150429-CA 14 2016 UT App 160Hutchings v. Labor Commission
rule” is not a basis on which we will disturb the Commission’s
medical causation determination, absent a showing that the
Commission embraced the same misunderstanding. See id. ¶ 24.
¶26 Here, we conclude that the questions the ALJ gave the
panel neither distorted the medical causation test nor neglected
the concept of aggravation; rather, the questions required the
panel to consider whether the accident contributed to
Hutchings’s current low back condition in any degree. The first
question posed to the panel was nearly verbatim the medical
causation test articulated in Allen v. Industrial Commission, 729
P.2d 15 (Utah 1986). See id. at 27 (“The purpose of the medical
cause test is to ensure that there is a medically demonstrable
causal link between the work-related exertions and the
unexpected injuries that result from those strains.”). And the
second and third questions required the panel to consider
whether any “percentage of [Hutchings’s] whole person
impairment” or “medical or functional capacity limitations” was
caused by the accident. These questions directed the panel to
consider whether the accident caused any portion of the low
back condition for which Hutchings sought compensation. As a
result, we cannot agree with Hutchings’s assertion that the
medical panel was incorrectly instructed regarding the medical
causation test.
B. The Medical Panel’s and the Commission’s Medical
Causation Analyses
¶27 We also conclude that the Commission’s medical
causation determination was based on an appropriate analysis of
the facts and applicable law. Hutchings contends that neither the
medical panel nor the Commission considered the accident as a
medical cause of her low back condition. But it is clear from the
record that both the medical panel and the Commission
determined that Hutchings’s low back condition was the sole
medical result of a preexisting condition by appropriately
considering the entire medical history in relation to the accident.
20150429-CA 15 2016 UT App 160Hutchings v. Labor Commission
Cf. Resort Retainers v. Labor Comm’n, 2010 UT App 229, ¶ 29, 238
P.3d 1081 (concluding that the Commission properly adopted
the medical panel’s report, in part because the Commission
“considered the evidence, which included reports in conflict
with the medical panel’s recommendations, before it adopted the
findings of the medical panel” and that the medical panel
“similarly considered all of the evidence”).
¶28 First, the medical panel made its causation findings after
examining Hutchings and conducting an extensive review of her
medical history. Indeed, six out of ten pages of the medical
panel’s report are an exhaustive recitation of the medical history
related to Hutchings’s low back condition, beginning in
December 2006 with her first low back pain appointment with
Dr. Staheli and ending with Dr. Major’s assessment in 2012.
Further, the medical panel analyzed Hutchings’s back condition
in the context of her medical history as a whole and based its
medical causation conclusions on specific evidence in the
medical record. For example, in response to the ALJ’s question of
whether there was a medically demonstrable causal connection
between Hutchings’s low back condition and her accident, the
medical panel referenced Hutchings’s reports of low back pain
before her accident, the MRI studies, Dr. Staheli’s and Dr. Britt’s
medical reports, the events between the accident and
Hutchings’s December 2008 appointment with Dr. Staheli in
which she first reported low back pain to a medical provider,
and Dr. Snook’s surgical findings. Based on this history, the
panel determined that “the [medical record] information . . .
does not allow the medical panel to find any reasonable
demonstrable causal connection between Mrs. Hutchings[’s] low
back condition and the industrial accident which occurred in
August 2008.”
¶29 The ALJ then determined that Hutchings had “failed to
meet her burden of proof regarding medical causation” because
she had “reviewed the medical record and [found] the panel’s
analysis consistent with the record and supported by the opinion
20150429-CA 16 2016 UT App 160Hutchings v. Labor Commission
of Dr. Knoebel.” The Commission’s own assessment of the
medical record also tracked the medical panel’s medical
causation opinion and appropriately adopted the medical
panel’s reasoning. See id. (determining that it was proper for the
Commission to adopt the medical panel report where the
Commission “considered all the evidence, as it is required to
do, and ultimately found that the medical panel’s opinions
were . . . persuasive” (footnote omitted)). The Commission
determined that “[a]fter reviewing the medical evidence and
the medical panel’s report,” Hutchings’s “low-back condition
was not medically caused by the work accident.” In making
this determination, the Commission extensively reviewed
Hutchings’s medical history as well as the medical panel’s
findings and analysis. In particular, it described the evidence it
found in the record to be supportive of the medical panel’s
conclusions. For example, the Commission noted that the
imaging studies the panel relied on “revealed longstanding
degenerative changes in [Hutchings’s] low back”; that the
panel’s reasoning was “supported by the findings of Dr. Snook,
who also assessed Ms. Hutchings with degeneration in her
lumbar spine and confirmed such degeneration postoperatively”;
that “Dr. Snook’s findings of only degenerative changes rather
than an acute injury appear to contradict Dr. Staheli’s [initial]
diagnosis of a ‘herniated lumbar disk’”; that Dr. Staheli later
assessed Hutchings with “degenerative disc disease, arthritis
and a lumbar-spine cyst”; and that “Dr. Knoebel opined that Ms.
Hutchings’s low-back problems are due to pre-existing
degeneration.” Based on this evidence, the Commission
concluded that the record supported the medical panel’s
determination that Hutchings’s low back condition was “due to
pre-existing degeneration” and that the panel had “appropriately
addressed the medical aspects of the claim including the central
issue of medical causation.” Under the circumstances, it is
apparent that both the medical panel and the Commission
assessed the medical evidence in the record to determine
whether the accident medically caused Hutchings’s current low
20150429-CA 17 2016 UT App 160Hutchings v. Labor Commission
back condition. Accordingly, we are not persuaded by
Hutchings’s argument that the Commission improperly applied
or analyzed the medical causation test.
C. Substantial Evidence Supporting the Commission’s
Medical Causation Finding
¶30 Hutchings next contends that the evidence does not
support the medical panel’s or the Commission’s medical
causation determinations. In particular, she contends that the
evidence supports her claim that the accident aggravated her
preexisting, asymptomatic low back condition. The Commission’s
medical causation finding is entitled to “substantial deference” so
long as it is supported by substantial evidence. See Danny’s
Drywall v. Labor Comm’n, 2014 UT App 277, ¶ 11, 339 P.3d 624.
“Substantial evidence is more than a mere scintilla of
evidence . . . though something less than the weight of the
evidence,” and the substantial evidence test is met “when a
reasonable mind might accept as adequate the evidence
supporting the decision.” See Cook v. Labor Comm’n, 2013 UT App
286, ¶ 14, 317 P.3d 464 (omission in original) (citations and
internal quotation marks omitted). We will not “reweigh the
evidence and independently choose which inferences we find to
be most reasonable”; rather, we defer to the Commission’s
findings “when reasonably conflicting views arise,” as it is the
Commission’s “province to draw the inferences and resolve
these conflicts.” Danny’s Drywall, 2014 UT App 277, ¶ 11
(citations and internal quotation marks omitted). “In other
words, we will not overturn [the Commission’s] factual findings
if they are based on substantial evidence, even if another
conclusion from the evidence is permissible.” Allied Constr. &
Dev., Inc. v. Labor Comm’n Appeals Bd., 2013 UT App 224, ¶ 2, 310
P.3d 1230 (citation and internal quotation marks omitted). But
rather than demonstrate that there is no substantial evidence to
support the Commission’s decision, Hutchings focuses on
evidence in the record that she contends requires a different
20150429-CA 18 2016 UT App 160Hutchings v. Labor Commission
conclusion—that the accident aggravated her preexisting low
back condition.
¶31 According to Hutchings, the evidence shows that at the
time of the August 2008 accident she immediately suffered new
and unprecedented back pain and radicular pain; she then
experienced ongoing mobility limitations and needed staff
assistance to do her work; and she eventually underwent spinal
surgery and other treatment. This sequence of events, she
argues, conclusively establishes that the accident caused her
disability. She also directs us to medical reports that she claims
correctly considered the aggravation rule and, as a result,
concluded that the accident aggravated whatever preexisting
condition contributed to her pain and need for surgery. But this
evidence does not require a conclusion that the Commission’s
decision is unsustainable. Hutchings must do more than point us
to facts or pieces of evidence that she contends support her
arguments on appeal. See Carbon County v. Department of
Workforce Servs., 2012 UT App 4, ¶¶ 5, 8, 269 P.3d 969. Instead,
Hutchings must demonstrate that the Commission’s medical
causation finding itself is not supported by substantial evidence.
See Danny’s Drywall, 2014 UT App 277, ¶ 11. And there is
substantial evidence in the record that conflicts with Hutchings’s
view and from which the Commission could reasonably have
found that Hutchings’s low back condition resulted entirely
from degenerative changes and not from acute injury.
¶32 To begin with, the medical panel’s report alone provides
substantial evidence to support the Commission’s medical
causation determination. See Cook, 2013 UT App 286, ¶¶ 14–20
(concluding that the medical panel report constituted substantial
evidence to support the Board’s finding that there was no
medical causation where the panel report was thorough and the
conclusion was explained by reference to the factual findings
from the evidentiary hearing, the claimant’s medical history, and
“relevant medical literature”). The ALJ and the Commission
noted that the medical panel in this case was comprised of two
20150429-CA 19 2016 UT App 160Hutchings v. Labor Commission
doctors who were both orthopedic surgeons, diplomates of the
American Board of Orthopedic Surgery, and licensed to practice
medicine in Utah. Further, the medical panel report noted that
“[b]oth physicians met, interviewed, and examined” Hutchings
after which they conferred and reached unanimous conclusions
in their report. And, as discussed above, it is clear that the
medical panel reached its findings and conclusions only after
examining Hutchings and exhaustively reviewing her medical
history. Further, as discussed below, the medical panel’s
ultimate conclusion—that Hutchings’s low back condition is the
medical result of continuing degenerative changes that predated
her accident—is corroborated by the evidence it referenced. As a
result, the medical panel’s report constitutes substantial
evidence in its own right.
¶33 Moreover, with respect to the medical record as a whole,
the Commission noted that there was evidence that undermined
Hutchings’s claim that the August 2008 accident caused or
aggravated her preexisting low back condition, a conclusion
implicit in the medical panel’s analysis. For example, the record
demonstrates that Hutchings did not miss work due to her low
back pain, that she had previously managed her low back pain
with medication, and that she did not mention her low back pain
to Dr. Britt during an evaluation for a different work injury in
November 2008. And when she was finally seen by Dr. Britt in
December 2008 for low back pain, he noted that there had been
no specific trauma—rather, he noted that the first of the school
year always involved heavy lifting—and that Hutchings’s pain
had only worsened in the prior few weeks.
¶34 Indeed, multiple doctors diagnosed her low back
condition as degenerative. For example, Hutchings’s surgeon,
Dr. Snook, assessed her with spinal degeneration on multiple
vertebral levels and a degenerative cyst. Her primary care
physician, Dr. Staheli, later assessed her with degenerative
disc disease, arthritis, and a spinal cyst. Dr. Major diagnosed
her with a degenerative vertebral condition and joint disease.
20150429-CA 20 2016 UT App 160Hutchings v. Labor Commission
Dr. Knoebel, after examining Hutchings and reviewing the
medical records, noted that the findings in the record indicated
that Hutchings suffered from a “degenerative low back
condition” that was not reasonably probable to have been
“secondary” to the “lifting incident.” And the medical panel,
also after examining Hutchings and reviewing her medical
history and the imaging studies, concluded that Hutchings was
suffering from multiple degenerative spinal conditions.
¶35 Further, it does not appear that any medical report in the
record characterized any particular spinal condition from which
Hutchings was suffering—whether bulging discs or some other
condition—as evidence that Hutchings had suffered an acute
trauma or injury from her accident. While several medical
reports noted Hutchings’s accident as part of her history, no
report linked that accident with a specific spinal condition.
Indeed, the closest a report came to doing so was Dr. Britt’s
assessment in December 2008 that Hutchings had a “blown disc”
in her lower back that had “to be work related.” But even this
statement was qualified by other statements in the same report
that indicated that there was “[n]o specific trauma,” indicated
that the pain had only worsened in the preceding four weeks,
and attributed the blown disc to exertions during the “[first] of
the year [when Hutchings] always has to do a lot of heavy
lifting.” Thus, the medical record contains substantial evidence
that, whatever pain or injury Hutchings may have suffered from
the accident, the disability underlying her compensation claim
resulted from degenerative spinal conditions, not the accident
itself.
¶36 To be sure, as Hutchings has pointed out, there is also
conflicting medical evidence that the accident aggravated or
medically affected her preexisting low back condition, not least
Hutchings’s own description of the accident and its aftermath.
But it is the Commission’s prerogative to resolve the conflicts in
the evidence, and it did so. See Cook v. Labor Comm’n, 2013 UT
App 286, ¶ 20, 317 P.3d 464. For example, Hutchings points to
20150429-CA 21 2016 UT App 160Hutchings v. Labor Commission
the MRI studies as well as the reports of Dr. Major and
Dr. Staheli as evidence that the accident aggravated her low back
condition. But the Commission found that the “imaging studies
on Ms. Hutchings’s lumbar spine . . . revealed longstanding
degenerative changes in her low back rather than an acute
injury,” and the evidence supports this finding. While the
December 2008 MRI studies suggested that Hutchings’s pain
could have been due to a herniated disc that was compressing on
a nerve in her lower back, those studies also indicated that she
was suffering from degenerative disc disease on multiple levels
as well as several other spinal conditions that, as the medical
panel found, were unlikely products of her accident. Further, as
the Commission noted, the suggestion of a herniated disc in the
2008 MRI studies was directly refuted by Dr. Snook’s surgical
report in February 2009. Dr. Snook indicated that he did not
perform any disc surgery because during surgery he discovered
that, despite the suggestion in the MRI studies, the disc at issue
was not compressing a nerve root in Hutchings’s lower back.
Instead, his pre- and postoperative diagnosis was that Hutchings
was suffering from a degenerative spinal condition and a cyst
“encroaching on [a] nerve” in her lower back. His later reports
indicate that he explained to Hutchings that it was unlikely the
cyst was caused by her work.4
4. Hutchings characterizes Dr. Snook’s surgical report as
describing a flat disc only after he performed the surgery to
decompress her nerve, suggesting that it was the surgery itself
that flattened the disc. However, Dr. Snook’s report more
reasonably supports a conclusion that he did not perform any
disc-related procedures because he discovered after the surgery
began that the disc was already “flat.” He stated that “[t]here
was some suggestion” of a herniated disc in Hutchings’s lower
back but further noted that he “did not see any evidence of that
at the time of surgery.”
20150429-CA 22 2016 UT App 160Hutchings v. Labor Commission
¶37 In addition, Hutchings points out that Dr. Major indicated
that a definite percentage of Hutchings’s body impairment and
her low back condition were related to her work injury and that
Dr. Staheli opined that Hutchings’s “physical and/or mental
limitations were . . . in whole or in part caused, aggravated or
accelerated by and [were] a direct result of [Hutchings’s]
industrial injury.” But, even if there are medical reports in the
record that support a conclusion that Hutchings’s low back
condition was aggravated by her accident, we will not disturb
the Commission’s finding where there is other substantial
evidence in the record to support the Commission’s
determination that Hutchings’s low back condition is not the
medical result of her industrial accident. Id. (“It is the
[Commission’s] responsibility to resolve conflicts in the evidence
that come before it.”). It is also the Commission’s prerogative to
weigh the evidence and to rely on the evidence that it considers
most credible. See id. (“[The Commission] may choose to give
certain evidence more weight than other evidence.” (citation and
internal quotation marks omitted)). And here, the Commission
relied on the medical panel report and several individual
doctors’ reports, as well as Dr. Knoebel’s evaluation, to
ultimately determine that Hutchings’s low back condition was
not medically caused by her accident. Although the Commission
might have reached a different decision based on the evidence,
we will not disturb the Commission’s determination merely
because “another [determination] from the evidence is
permissible.” Green v. Labor Comm’n, 2013 UT App 165, ¶ 3, 306
P.3d 824 (citation and internal quotation marks omitted).
¶38 Thus, we conclude that while the accident itself might
have been the legal cause of some harm or injury to Hutchings,
the Commission’s decision that the disability for which she has
claimed compensation was not medically caused by the accident
is supported by substantial evidence in the whole record,
20150429-CA 23 2016 UT App 160Hutchings v. Labor Commission
including the medical panel’s assessment. 5 Accordingly, we
decline to disturb the Commission’s medical causation
determination.
CONCLUSION
¶39 Hutchings has failed to demonstrate that the Commission
incorrectly applied the medical causation test or that the
Commission’s medical causation determination was not
supported by substantial evidence. For these reasons, we decline
to disturb the Commission’s order.
5. Because we conclude that there was substantial evidence
supporting the Commission’s medical causation determination,
we decline to address Hutchings’s argument that there was not
sufficient evidence for the medical panel (and, later, the
Commission) to conclude that she was suffering from chronic
low back pain before her accident. Furthermore, nothing in the
Commission’s own medical causation determination suggests
that it primarily relied on a finding that Hutchings had suffered
from chronic low back pain at the time of her accident. Indeed,
the Commission specifically noted in its order affirming the
ALJ’s decision that even if Dr. Staheli’s multiple references to
low back pain before her accident were mistaken, those
references “are not the only evidence relied upon by the medical
panel.”
20150429-CA 24 2016 UT App 160