Mark Ferrell v. Northwest Hardwoods ( 2023 )


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  •                                                                                  FILED
    January 19, 2023
    EDYTHE NASH GAISER, CLERK
    SUPREME COURT OF APPEALS
    OF WEST VIRGINIA
    STATE OF WEST VIRGINIA
    SUPREME COURT OF APPEALS
    MARK FERRELL,
    Claimant Below, Petitioner
    vs.)   No. 21-0208 (BOR Appeal No. 2055820)
    (Claim No. 2013025135)
    NORTHWEST HARDWOODS,
    Employer Below, Respondent
    MEMORANDUM DECISION
    Petitioner Mark Ferrell, by counsel Lori J. Withrow, appeals the decision of the West
    Virginia Workers’ Compensation Board of Review (“Board of Review”). Northwest Hardwoods,
    by counsel Daniel G. Murdock, filed a timely response.
    The issue on appeal is compensability of additional components in the claim. The claims
    administrator denied the request to add left knee pain, left pes anserine bursitis, and left knee mild
    osteoarthritis as compensable diagnoses in the claim on May 31, 2019. On October 9, 2020, the
    Workers’ Compensation Office of Judges (“Office of Judges”) affirmed the claims administrator’s
    decision. This appeal arises from the Board of Review’s Order dated February 19, 2021, in which
    the Board affirmed the Order of the Office of Judges.
    This Court has considered the parties’ briefs and the record on appeal. The facts and legal
    arguments are adequately presented, and the decisional process would not be significantly aided
    by oral argument. This case satisfies the “limited circumstances” requirement of Rule 21(d) of the
    Rules of Appellate Procedure and is appropriate for a memorandum decision rather than an
    opinion.
    The standard of review applicable to this Court’s consideration of workers’ compensation
    appeals has been set out under West Virginia Code § 23-5-15, in relevant part, as follows:
    (c) 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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    (d) 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
    reweighing of the evidentiary record . . . .
    See Hammons v. W. Va. Off. of Ins. Comm’r, 
    235 W. Va. 577
    , 582-83, 
    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. Off. of
    Ins. Comm’r, 
    227 W. Va. 330
    , 334, 
    708 S.E.2d 524
    , 528 (2011).
    Mr. Ferrell filed a workers’ compensation claim for a work injury which occurred on March
    20, 2013. According to his application for benefits, a strong wind blew a piece of tin into his leg
    and knocked him down. Initially, he was diagnosed with a left knee contusion, and the claim was
    held compensable on April 2, 2013. Mr. Ferrell continued to have persistent pain and recurrent
    effusion in the left knee. He was evaluated by Joseph Grady, M.D., on February 11, 2014. Dr.
    Grady concluded that Mr. Ferrell’s diagnosis had not been definitively established, and diagnostic
    arthroscopy was recommended. An operative report from Davis Medical Center indicates that Mr.
    Ferrell underwent arthroscopic surgery on his left knee on March 28, 2014. The surgical
    exploration revealed a medial plica that was excised. There were no abnormalities involving the
    meniscus, femoral condyle, tibial plateau, posterior cruciate ligament, or anterior cruciate ligament
    of the left knee. The post-operative diagnosis was left knee medial plica pain.
    An MRI of Mr. Ferrell’s knee performed on June 18, 2015, revealed: 1) intact anterior
    cruciate and posterior cruciate ligaments; 2) stable appearance of the anterior horn of the medial
    meniscus with apparent truncation, but no significant interval change when compared to a prior
    left knee MRI from July 23, 2013; 3) resolution of the bone contusion of the lateral tibial plateau
    and the grade 1 medial collateral ligament sprain; and 4) a small Baker’s cyst with minimal joint
    fluid. An arthrogram of Mr. Ferrell’s hip was performed on October 30, 2015, to address pain in
    the medial aspect of the left knee.
    Mr. Ferrell was evaluated by Karim Boukhemis, M.D., and E. Barry McDonough, M.D.,
    with the West Virginia University Department of Orthopedics, on August 19, 2016, for his
    complaints of left knee pain. Physical examination of the left knee revealed no evidence of
    significant effusion, ecchymoses, abrasions, or lesions. There was no evidence of ligamentous
    laxity with Lachman, posterior drawer, or varus/valgus testing. However, there was some
    tenderness along the medial joint line. X-rays of the left knee revealed no evidence of significant
    arthritis or osseous abnormalities, deformities, or fractures. The assessment was left knee pain with
    minor arthritis. Dr. Boukhemis and Dr. McDonough did not feel surgical intervention was
    warranted, and they recommended conservative treatment in the form of physical therapy and a
    brace.
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    Mr. Ferrell was evaluated by Mohamed Fahim, M.D., at the Pain Management Center, on
    September 20, 2016. Physical examination of the left lower extremity revealed no objective
    abnormalities to light touch. Dr. Fahim’s assessment was chronic left knee pain and osteoarthritis
    of the left knee. Dr. Fahim recommended left knee diagnostic nerve blocks and possible
    radiofrequency ablation. On October 21, 2016, Mr. Ferrell underwent a left knee nerve block with
    Dr. Fahim. However, Mr. Ferrell had limited response to the procedure and noted that his pain
    level reduced from 8/10 to 5/10. Dr. Fahim had said if the procedure did not reduce the pain by at
    least 50%, it was not worth continuing the treatment.
    On March 3, 2017, Mr. Ferrell was seen by Russell Biundo, M.D., a neurosurgeon, for left
    knee pain. Dr. Biundo noted that Mr. Ferrell developed left knee pain, discomfort, and mild joint
    swelling after he was struck by a 16-foot piece of aluminum. It was noted that Mr. Ferrell reported
    little improvement following left knee arthroscopy, physical therapy, and pain injections. Physical
    examination found tenderness present over the medial joint line with slight patellofemoral
    crepitation. Dr. Biundo diagnosed Mr. Ferrell with left knee pain related to a degenerative
    meniscus and degenerative medial joint line. A whole-body bone scan was recommended to
    evaluate possible arthritic changes across the left knee.
    A three-phase Bone Scan report dated April 4, 2017, revealed no significant abnormal
    tracers within Mr. Ferrell’s skeleton or knees. The impression was a slight increased tracer in the
    left tibia. He returned to Dr. Biundo for a follow-up examination on May 23, 2017, and it was
    opined that the imaging findings were most consistent with degenerative joint disease of the left
    knee with ongoing pain and discomfort. Dr. Biundo recommended a brace for Mr. Ferrell’s left
    knee.
    Mr. Ferrell was seen by Christopher Courtney, D.O., and Justin Brewer, PA-C, on February
    1, 2018, for continued left knee pain. Physical examination of the left knee revealed mild palpable
    tenderness over the medial femoral condyle and pes anserine tendon. Mild crepitus was noted with
    passive range of motion. Mr. Ferrell demonstrated full passive range of motion of the left knee.
    There was no evidence of patella instability or effusion. Lachman, McMurry, and Posterior Drawer
    tests were all negative. X-rays revealed minimal degenerative osteoarthritis of the left knee. Dr.
    Courtney’s and Mr. Brewer’s assessment was left knee osteoarthritis and pes anserine tendinitis
    bursitis. Mr. Ferrell later received pes anserine and intra-articular joint injections on February 1,
    2018; May 30, 2018; and August 23, 2018. In a progress note from Dr. Courtney and Mr. Brewer
    dated November 26, 2018, it was noted that Mr. Ferrell reported relief following his injections.
    On November 26, 2018, Dr. Courtney requested a diagnosis update in the claim to include
    left knee pain following injury, left pes anserine bursitis, and left knee osteoarthritis. In support of
    his request, Dr. Courtney stated:
    Patient states his left knee pain has improved since starting left knee joint and pes
    anserine bursa type injections. He does continue to have 5-6/10 pain with most
    activities. He stated he has pain with walking, standing, climbing and crawling. He
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    states there are activities he is unable to do. Some of these include climbing,
    carrying heavy items, ladders, and walking on unsteady terrain.
    On May 31, 2019, the claims administrator denied Dr. Courtney’s request to add left knee pain,
    left pes anserine bursitis, and left knee osteoarthritis as compensable diagnoses in the claim. Mr.
    Ferrell protested the claims administrator’s decision.
    Mr. Ferrell continued to be treated with pes anserine tendon and intra-articular joint
    injections of the left knee. On November 8, 2019, Dr. Courtney submitted a letter noting that he
    has been treating Mr. Ferrell for ongoing left knee pain since November 1, 2017. The letter listed
    Mr. Ferrell’s diagnoses as left knee osteoarthritis and pes anserine bursitis tendinitis, and his
    treatment consisted of injections every three to four months. Additionally, Dr. Courtney stated:
    The patient has a remote injury history of a work-related injury which occurred
    around 2013. The patient continued to complain of medial left knee joint pain and
    pes anserine knee joint pain. He relates an injury to this area in 2013 as the cause
    and effect of his ongoing problem. The patient has gotten sufficient relief with
    injection management. The patient continues to complain of daily pain despite
    conservative treatments. He states he has pain with walking, standing, climbing and
    doing other work related activities.
    Our recommendation is that he continue to follow-up for injection management as
    this is helping him with his daily activities. The patient states that without these
    injections he is unable to continue his standard work duties. He states that he has
    been able to continue working despite this previous injury. His ongoing diagnosis
    with us once again is pes anserine tendinitis/bursitis and left knee osteoarthritis.
    An Independent Medical Evaluation report from ChuanFang Jin, M.D., dated January 9,
    2020, detailed Mr. Ferrell’s medical history. Physical examination of the left knee revealed
    significant palpable tenderness over the medial joint line. Range of motion of the left knee was
    fairly normal. There was no crepitus on passive range of motion and no evidence of ligament laxity
    or joint effusion. There was no evidence of varus or valgus deformity. Dr. Jin found Mr. Ferrell to
    be at maximum medical improvement regarding his compensable left knee contusion of March 20,
    2013. Dr. Jin noted that the bone contusion had resolved according to the most recent imaging
    evidence. Dr. Jin further opined that the evidence of degenerative disease in the left knee was not
    related to the compensable injury of March 20, 2013. Regarding the diagnosis of left knee pain,
    Dr. Jin noted that pain is a symptom and the left knee pain is not causally related to the
    compensable injury and was most likely due to degenerative arthrosis of the left knee. Dr. Jin also
    addressed the diagnosis of left pes anserine bursitis and noted that the diagnosis was not made until
    more than four years after the reported injury. From a temporal standpoint, Dr. Jin opined that the
    diagnosis of left pes anserine bursitis was not causally related to the compensable injury but was
    most likely related to a chronic pathology of degenerative arthrosis of the left knee. Finally, Dr.
    Jin opined that Mr. Ferrell’s left knee osteoarthritis should not have been caused by his
    compensable injury of March 20, 2013. She concluded that no causal relationship had been
    established regarding the compensable injury and the diagnosis of left knee osteoarthritis. Dr. Jin
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    stated that Mr. Ferrell’s left knee osteoarthritis is a preexisting condition and is not caused or
    causally related to the injury in the claim.
    In a Final Decision dated October 9, 2020, the Office of Judges concluded that Mr. Ferrell
    has failed to show by a preponderance of evidence that the requested diagnoses should be added
    as compensable conditions in the claim. The Office of Judges also denied the addition of left knee
    pain as a diagnosis because pain is a symptom, not a diagnosis. Additionally, it was found that Dr.
    Jin opined that Mr. Ferrell’s current symptoms are due to nonoccupational left knee degenerative
    arthritis as opposed to the compensable left knee contusion of March 20, 2013.
    The Office of Judges determined that the weight of the medical evidence in the claim does
    not support the addition of left pes anserine bursitis as a compensable diagnosis in the claim
    because there is no medical evidence to corroborate Dr. Courtney’s medical diagnosis of the
    condition. Even if the diagnosis of pes anserine bursitis is accurate, the Office of Judges found that
    Mr. Ferrell has failed to show by a preponderance of the evidence that the diagnosis is causally
    related to the compensable injury of March 20, 2013. In fact, Dr. Jin specifically opined that the
    diagnosis of pes anserine bursitis is most likely related to nonoccupational degenerative arthritis
    of Mr. Ferrell’s left knee as opposed to the compensable injury.
    Finally, the Office of Judges found that the medical evidence does not establish that Mr.
    Ferrell’s left knee osteoarthritis is causally related to the compensable injury of March 30, 2013.
    Although Dr. Courtney requested that left knee osteoarthritis be added as a compensable diagnosis
    in the claim, the Office of Judges found that Mr. Ferrell has offered no medical evidence to support
    a causal connection between the diagnosis and the compensable injury. It was noted that none of
    the other physicians in the record opined that Mr. Ferrell’s left knee osteoarthritis is causally
    related to the compensable left knee contusion of March 30, 2013. Accordingly, the Office of
    Judges affirmed the claims administrator’s Order of May 31, 2019. By Order dated February 19,
    2021, the Board of Review adopted the findings of fact and conclusions of law of the Office of
    Judges and affirmed the decision.
    On appeal, Mr. Ferrell argues that he has complained of left knee pain since his work-
    related injury on March 30, 2013, and there is no evidence of record that he had been diagnosed
    and/or treated for either left pes anserine bursitis or mild osteoarthritis prior to the date of injury.
    Dr. Courtney, his treating physician, completed a diagnosis update and opined that the conditions
    should be added to the claim because it is more likely than not that the traumatic work-related
    injury is the cause of Mr. Ferrell’s pes anserine bursitis and osteoarthritis. The Office of Judges
    rejected Mr. Ferrell’s arguments and stated that his current symptoms are most likely due to
    nonoccupational left knee degenerative arthritis, as opposed to the compensable left knee
    contusion of March 20, 2013. In syllabus point 3 of Gill v. City of Charleston, 
    236 W. Va. 737
    ,
    
    783 S.E.2d 857
     (2016), this Court created a general rule that:
    [a] noncompensable preexisting injury may not be added as a compensable
    component of a claim for workers’ compensation medical benefits merely because
    it may have been aggravated by a compensable injury. To the extent that the
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    aggravation of a noncompensable preexisting injury results in a [discrete] new
    injury, that new injury may be found compensable.
    Syllabus Point 5 of Moore v. ICG Tygart Valley, LLC, ___ W. Va. ___, 
    879 S.E.2d 779
     (W.
    Va. 2022), states:
    [a] claimant’s disability will be presumed to have resulted from the compensable
    injury if: (1) before the injury, the claimant’s preexisting disease or condition was
    asymptomatic, and (2) following the injury, the symptoms of the disabling disease
    or condition appeared and continuously manifested themselves afterwards. There
    still must be sufficient medical evidence to show a causal relationship between the
    compensable injury and the disability, or the nature of the accident, combined with
    the other facts of the case, raises a natural inference of causation. This presumption
    is not conclusive; it may be rebutted by the employer.
    Because the evidence of record raises a possible inference of causation for Mr. Ferrell’s
    pes anserine bursitis and osteoarthritis, the Board of Review’s Order dated February 19, 2021, is
    reversed. This case is remanded to the Board of Review for a further review of Mr. Ferrell’s request
    to add pes anserine bursitis and osteoarthritis to the claim under Moore.
    Reversed and Remanded with directions.
    ISSUED: January 19, 2023
    CONCURRED IN BY:
    Chief Justice Elizabeth D. Walker
    Justice Tim Armstead
    Justice John A. Hutchison
    Justice William R. Wooton
    Justice C. Haley Bunn
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