Ambrozik v. Stonebrook, Inc. ( 2021 )

STATE OF WEST VIRGINIA
SUPREME COURT OF APPEALS
LINDA M. AMBROZIK,
FILED
Claimant Below, Petitioner
May 20, 2021
EDYTHE NASH GAISER, CLERK
vs.) No. 20-0271 (BOR Appeal No. 2054980) SUPREME COURT OF APPEALS
OF WEST VIRGINIA
(Claim No. 2018016300)
STONEBROOK, INC.,
Employer Below, Respondent
MEMORANDUM DECISION
Petitioner Linda M. Ambrozik, by Counsel J. Thomas Greene Jr. and T. Colin Greene,
appeals the decision of the West Virginia Workers’ Compensation Board of Review (“Board of
Review”). Stonebrook, Inc., by Counsel Alyssa A. Sloan, filed a timely response.
The issue on appeal is medical benefits. The claims administrator denied authorization of
a total left knee replacement on March 13, 2019. The Workers’ Compensation Office of Judges
(“Office of Judges”) affirmed the decision in its December 27, 2019, Order. The Order was
affirmed by the Board of Review on February 28, 2020.
The Court has carefully reviewed the records, written arguments, and appendices contained
in the briefs, and the case is mature for consideration. The facts and legal arguments are adequately
presented, and the decisional process would not be significantly aided by oral argument. Upon
consideration of the standard of review, the briefs, and the record presented, the Court finds no
substantial question of law and no prejudicial error. For these reasons, a memorandum decision is
appropriate under Rule 21 of the Rules of Appellate Procedure.
The standard of review applicable to this Court’s consideration of workers’ compensation
appeals has been set out under W. Va. Code § 23-5-15, in relevant part, as follows:
(b) In reviewing a decision of the board of review, the supreme court of appeals
shall consider the record provided by the board and give deference to the board’s
findings, reasoning and conclusions[.]
....
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(c) If the decision of the board represents an affirmation of a prior ruling by both
the commission and the office of judges that was entered on the same issue in the
same claim, the decision of the board may be reversed or modified by the Supreme
Court of Appeals only if the decision is in clear violation of Constitutional or
statutory provision, is clearly the result of erroneous conclusions of law, or is based
upon the board’s material misstatement or mischaracterization of particular
components of the evidentiary record. The court may not conduct a de novo re-
weighing of the evidentiary record. . . .
See Hammons v. W. Va. Off of Ins. Comm’r, 235 W.Va. 577, 775 S.E.2d 458, 463-64 (2015). As
we previously recognized in Justice v. West Virginia Office Insurance Commission, 230 W. Va.
80, 83, 736 S.E.2d 80, 83 (2012), we apply a de novo standard of review to questions of law arising
in the context of decisions issued by the Board. See also Davies v. W. Va. Office of Ins. Comm’r,
227 W. Va. 330, 334, 708 S.E.2d 524, 528 (2011).
Ms. Ambrozik, a residential counselor, injured her head, left shoulder, and left knee when
she slipped and fell at work on January 12, 2018. Ms. Ambrozik reported to Berkeley Medical
Center on January 15, 2018, that she had a history of left knee problems and stated that she was
still undergoing regular treatment for the left knee. X-rays showed osteoarthritis but no fractures.
Ms. Ambrozik was diagnosed with left shoulder, left knee, and cervical arthritis as well as cervical
strain with radiculopathy. The January 15, 2018, Employer’s Report of Injury indicated Ms.
Ambrozik fell at work and injured her head, left knee, and left shoulder. It was noted that she had
a prior left knee injury for which she was wearing a brace. The claim was held compensable for
neck sprain, left shoulder contusion, and left knee contusion on January 25, 2018.
An April 12, 2018, left knee MRI showed a complex tear of the body and posterior horn of
the medial meniscus, end stage cartilage disease in the medial compartment, and small joint
effusion with a small cyst. The claims administrator granted authorization for a left knee
meniscectomy/chondroplasty on June 5, 2018. The surgery was performed on July 12, 2018, by
Joseph Cincinnati, M.D., who indicated the surgery was necessary to treat a medial meniscus tear
and degenerative joint disease. The postoperative diagnoses were large complex degenerative tear
of the medial meniscus, Grade 4 degenerative medial compartment joint disease, Grade 3/4
degenerative patellofemoral joint disease, and peripheral lateral meniscus tear. Dr. Cincinnati
requested authorization for a total left knee replacement on September 11, 2018.
Rebecca Thaxton, M.D., performed a Physician Review on September 13, 2018, in which
she recommended a second opinion regarding what conditions necessitate a total left knee
replacement. She stated that the surgery is clearly required to treat preexisting arthritis, but an
orthopedic evaluation is necessary to determine if the compensable injury contributed to the need
for surgery.
In a November 29, 2018, independent medical evaluation, Rafael Steuart, M.D., noted that
Ms. Ambrozik reported that her July 12, 2018, injury worsened her left knee pain. Dr. Steuart
reviewed operative pictures from the surgery and opined that they were consistent with severe
medial compartment arthritis. Dr. Steuart stated that all treatment in this claim was aimed at
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treating preexisting conditions. He asserted that Ms. Ambrozik’s meniscal tear was degenerative
in nature, which is almost always seen in patients with Ms. Ambrozik’s severity of osteoarthritis.
Dr. Steuart recommended no further left knee treatment for the compensable injury and opined
that a total left knee replacement is not necessary.
Dr. Thaxton performed a Physician Review on December 20, 2018, in which she opined
that a total left knee replacement is unnecessary treatment for the compensable injury. She stated
that the surgery was necessary to treat significant preexisting osteoarthritis. The claims
administrator denied authorization of a total left knee replacement on March 13, 2019.
Ms. Ambrozik testified in a July 29, 2019, deposition that on the day she was injured, she
was having no issues with her left knee. Since her July 12, 2018, surgery, she has had constant
pain that was not present prior to the compensable injury. Ms. Ambrozik admitted that she had left
knee injections before the compensable injury occurred to treat arthritis. Ms. Ambrozik also
admitted that when she was treated by Dr. Cincinnati in 2017, he told her that she would eventually
need a total left knee replacement.
In an August 30, 2019, deposition, Dr. Cincinnati testified that he first saw Ms. Ambrozik
for the compensable injury on May 1, 2018. At that time, he reviewed a left knee MRI and found
a medial meniscus tear and Grade 3/4 thinning of the articular cartilage. Dr. Cincinnati stated that
he performed surgery on Ms. Ambrozik’s left knee and found significant arthritis. Dr. Cincinnati
opined that the compensable injury exacerbated the preexisting arthritis. He testified that Ms.
Ambrozik would have eventually required a total left knee replacement regardless of the
compensable injury. He stated that the work injury could have aggravated or exacerbated Ms.
Ambrozik’s preexisting arthritis and could have accelerated the condition. Dr. Cincinnati testified
that he treated Ms. Ambrozik for left knee arthritis prior to the compensable injury, and offered to
perform left knee surgery, which likely would have been a total knee replacement. Ms. Ambrozik
declined surgery at that time. When he performed surgery after the compensable injury to fix the
medial meniscus tear, Dr. Cincinnati found Grade 4 degenerative arthritis. Dr. Cincinnati testified
that such advanced degenerative changes require a total knee replacement.
The Office of Judges affirmed the claims administrator’s denial of authorization of a total
left knee replacement in its December 27, 2019, Order. The Office of Judges found the opinion of
Dr. Steuart to be persuasive. Dr. Steuart concluded in his independent medical evaluation that the
requested surgery was necessary to treat preexisting osteoarthritis, not the compensable injury.
The request for surgery was made by Dr. Cincinnati, who previously performed surgery on Ms.
Ambrozik’s left knee. He testified in a deposition that he observed severe arthritis in the left knee,
which would require a total knee replacement. The Office of Judges concluded that Ms. Ambrozik
underwent left knee surgery to treat a compensable meniscus tear, but a preponderance of the
evidence indicates a total left knee replacement is not necessary treatment for the compensable
injury. The Board of Review adopted the findings of fact and conclusions of law of the Office of
Judges and affirmed its Order on February 28, 2020.
After review, we agree with the reasoning and conclusions of the Office of Judges as
affirmed by the Board of Review. West Virginia Code § 23-4-3(a)(1) provides that the claims
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administrator must provide medically related and reasonably required sums for healthcare services,
rehabilitation services, durable medical and other goods, and other supplies. Ms. Ambrozik
sustained a compensable left knee meniscus tear, which was surgically repaired. She now requests
authorization for a total left knee replacement. A preponderance of the evidence indicates the
surgery is necessary due to significant preexisting arthritis, not the compensable injury. The
decision of the Board of Review is therefore affirmed.
Affirmed.
ISSUED: May 20, 2021
CONCURRED IN BY:
Chief Justice Evan H. Jenkins
Justice Elizabeth D. Walker
Justice Tim Armstead
Justice John A. Hutchison
Justice William R. Wooton
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