Wilhelm, Andrea v. Walgreen Co.

FILED
Mar 16, 2022
09:10 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT MURFREESBORO
ANDREA WILHELM, ) Docket No. 2021-05-0320
Employee, )
v. )
WALGREEN CO., ) State File No. 62588-2019
Employer, )
And )
AMERICAN ZURICH INS. CO., ) Judge Dale Tipps
Carrier. )
COMPENSATION ORDER GRANTING BENEFITS
The threshold issue in this case is whether the Court has jurisdiction to hear Ms.
Wilhelm’s claim for medical and disability benefits. If jurisdiction is proper, the Court
must determine whether the work accident was the primary cause of her need for knee-
replacement surgery. After a March 3, 2022 compensation hearing, the Court holds that it
has jurisdiction and Ms. Wilhelm is entitled to medical and permanent partial disability
benefits related to her knee replacement.
History of Claim
Ms. Wilhelm fell and injured her left knee at work on August 19, 2019. Walgreen
accepted the claim and provided medical benefits. This included treatment with Dr.
Jonathan Petit, who diagnosed a radial tear of the posterior horn of the medial meniscal
root and performed surgery to repair the tear in October. During the operation, Dr. Petit
saw evidence of a previous ACL repair and grade II to grade III chondromalacia in the
medial femoral condyle.
Ms. Wilhelm’s condition initially improved, but by April 2020, Dr. Petit concluded
the meniscal repair had failed and recommended a knee replacement. He referred her to
Dr. Scott McCall to discuss surgical options.
By the time Ms. Wilhelm saw Dr. McCall in June, she reported severe pain that was
limiting her daily activities and ability to work. He found that her knee had degenerated to
the point that it was now “bone on bone,” and he recommended a Stryker MAKO1 total
left-knee arthroscopy. Walgreen submitted the surgical recommendation to Utilization
Review, which denied the MAKO procedure as not medically necessary under the
treatment guidelines. Dr. McCall appealed the denial to the Bureau’s Medical Director,
who upheld the denial on July 27.
Ms. Wilhelm continued to treat with Dr. McCall and proceeded with the knee-
replacement surgery under her health insurance. Because the surgery was unauthorized,
Walgreen paid no temporary disability benefits.2 Ms. Wilhelm reached maximum medical
improvement on October 16, 2020, and returned to full-duty work at a higher wage than
she was earning at the time of her injury.
In his deposition, Dr. McCall identified the work injury as the primary cause of Ms.
Wilhelm’s need for knee replacement. He explained that a tear of the meniscal root is
problematic because it tends to allow the meniscus to sublux out of the joint, which he
characterized as essentially “a full, complete meniscectomy.” He went on: “You have no
intact fibers. That transfers all of the patient’s weight onto the articular cartilage of the
knee . . . which causes rapid progression of arthritis.”
Dr. McCall said that this is what happened to Ms. Wilhelm. Her post-surgery MRI
on February 22 showed eighty-percent extrusion of the meniscus. This meant that the
repair had failed, resulting in a rapid progression of arthritis. He testified that, without the
root tear, she would not have needed the knee replacement at that time. Dr. McCall also
explained that the scans, as well as what he observed during surgery, showed a progression
from mild chondromalacia to bone-on-bone in about six months. He added that this was
common, and he had seen similar degeneration in as little as three months after an
attempted root repair.
For these reasons, and because Ms. Wilhelm’s knee was functioning with no
problems before August 2019, Dr. McCall said the work injury was the primary cause of
her need for knee replacement. As for impairment, he assigned a rating of ten percent.
When asked about the impairment rating for just the meniscal repair surgery, Dr. McCall
stated it would have been three percent.
On cross-examination, Dr. McCall acknowledged that Ms. Wilhelm had ACL
reconstruction surgery for her left knee in 1998, but he said that it had not resulted in post-
traumatic arthritis. He stated, “If she was going to get post-traumatic arthritis from the
ACL, that would have already happened.”
1
“Stryker MAKO” refers to a robot-assisted surgical procedure.
2
The parties stipulated that Ms. Wilhelm received short-term disability benefits through a Walgreen-funded
program.
Dr. McCall was also shown a Physician Certification Form he signed in February
2021 certifying that Ms. Wilhelm no longer had the ability to perform her pre-injury
occupation. He did not remember signing the form or why he did. He suggested he might
have misread the form or made a mistake.
At Walgreen’s request, Dr. William Gavigan performed a records review and gave
a deposition. He agreed that knee-replacement surgery was a reasonable option to treat
Ms. Wilhelm’s arthritis. However, he said the need for knee replacement was “more than
fifty percent probability caused by the ongoing arthritis.” He felt that arthritis was a
degenerative condition from the old ACL injury because “the torn meniscus would not
result in the joint space narrowing that quickly.” Although he conceded that the meniscus
injury accelerated her condition, he maintained that the pre-existing arthritis was the
primary cause of her need for knee replacement.
Ms. Wilhelm testified that she had no problems or pain with her knee after she
recovered from the 1998 ACL repair. Her job required her to stand and walk about seven
or eight hours a day, and until this injury, she was able to do her work without any problems
or knee pain. Further, her knee did not affect her other daily activities.
Ms. Wilhelm asked the Court to award permanent partial disability benefits based
on Dr. McCall’s ten-percent impairment rating. She also asked that Walgreen pay the
medical bills from her knee replacement.
Walgreen contended that the Court does not have jurisdiction over the knee
replacement issue because she did not exhaust her administrative remedies before filing
her Petition for Benefit Determination. Alternatively, it argued her claim is barred because
her petition was not timely filed. Walgreen further claimed that Ms. Wilhelm is not entitled
to any benefits related to her knee replacement because the need for that procedure was not
primarily caused by her work injury.
Findings of Fact and Conclusions of Law
Ms. Wilhelm, as the employee in a workers’ compensation claim, has the burden of
proof on all essential elements of her claim. Scott v. Integrity Staffing Solutions, 2015 TN
Wrk. Comp. App. Bd. LEXIS 24, at *6 (Aug. 18, 2015). At a compensation hearing, she
must show by a preponderance of the evidence that she is entitled to the requested benefits.
Willis v. All Staff, 2015 TN Wrk. Comp. App. Bd. LEXIS 42, at *18 (Nov. 9, 2015).
Jurisdiction
Walgreen first argued that Ms. Wilhelm’s claim must be denied because she did not
comply with timing provisions in the Bureau’s Utilization Review regulations.
Specifically, it argued that she failed to timely file a petition after the Medical Director
upheld denial of the knee replacement.
Tennessee Compilation Rules and Regulations 0800-02-06-.07(6) (January, 2017)
provides that any party disagreeing with the Medical Director’s decision “may file a
Petition for Benefit Determination (PBD) with the Court of Workers’ Compensation
Claims within seven business days of the receipt of the determination.” Because the
Medical Director issued his decision in this case on July 27, 2020, and Ms. Wilhelm did
not file her petition until April 7, 2021, Walgreen contended she has no right to now contest
the denial. The Court disagrees for several reasons.
First, although Walgreen introduced a copy of the Medical Director’s letter into
evidence, Ms. Wilhelm testified that she never received it. Walgreen offered no evidence
to the contrary, including no proof as to when, how, or even if the letter was mailed. The
Court found Ms. Wilhelm to be a credible witness throughout the hearing and accepts this
testimony. Similarly, the parties submitted no evidence as to when Ms. Wilhelm first saw
the letter. Thus, the unrebutted proof is insufficient to determine when or if she received
the Medical Director’s decision. Under the explicit text of Rule 0800-02-06-.07(6), this
means the Court cannot find that the seven-day period was ever triggered.
Further, even if Ms. Wilhelm had received the denial notice, the effect of Rule 0800-
02-06-.07(6) is not what Walgreen argued. The rules do not suggest that the seven-day
period operates to limit injured employees’ access to the Court. Rather, other subsections
explain the consequence of missing the seven-day window. Rules 0800-02-06-.06(7)(a)
and 0800-02-06-.07(5) state that the Medical Director’s denial “shall remain effective for
a period of 6 months from the date of the decision” unless there is “material change
documented by the treating physician that supports a new review or other information that
was not used by the [reviewing physician] in making the initial decision.” In other words,
the Medical Director’s denials are not permanent. If Ms. Wilhelm had received the denial
and failed to file a petition within seven business days, the only effect in the rules would
have been a six-month waiting period before she could resubmit the surgical request to
Utilization Review. The rules do not preclude her filing a petition after the expiration of
that period.
Walgreen also argued that Ms. Wilhelm’s failure to file the petition within seven
days means that the Court has no jurisdiction over this claim because she failed to exhaust
her administrative remedies.3 It cited Tristar Centennial Med. Ctr. v. Pugh, No. M2016-
02470-SC-R3-WC, 2018 Tenn. LEXIS 63 (Tenn. Workers’ Comp. Panel Feb. 15, 2018), for
the proposition that “where a statute provides an administrative remedy, such remedy must
3
Walgreen argued in the alternative that Ms. Wilhelm failed to exhaust her administrative remedies because
she failed to appeal the Medical Director’s decision. This argument is without merit because, other than
filing a petition, the rules provide no other “appeal” or method of challenging the Medical Director’s
decision.
first be exhausted before the courts will act.” This is an accurate statement of law, but
Walgreen urged the Court to overlook the fact that Tristar was decided under prior law.
The Court cannot do this.
The Supreme Court has held that, “[U]nless the statute providing for an
administrative remedy requires exhaustion [of remedies] ‘by its plain words,’ an
administrative appeal is not mandatory[.] Absent a statutory mandate, the exhaustion of
the administrative remedies doctrine is a matter of judicial discretion.” Thomas v. State
Bd. of Equalization, 940 S.W.2d 563, 566 n.5 (Tenn. 1997).
Tennessee Code Annotated section 50-6-124 empowers the Bureau to establish a
utilization review program. Nothing in the current version of that section or the resulting
rules requires an employee to exhaust administrative remedies before filing a petition
seeking benefits after a Utilization Review denial. In fact, the administrative procedure of
filing a petition to challenge the Medical Director’s denial is couched in permissive (a party
“may file”), not mandatory, terms. Nothing in the plain words of the Workers’
Compensation Law or the Utilization Review regulations mandates that the only way to
challenge the Medical Director’s denial of treatment is to file a petition within seven
business days of that denial. At most, it might be argued that a Court is constrained from
acting on the issue until the six-month period expires. However, once six months have
passed, as here, even that argument is untenable. In this situation, the Court can consider
remedies sought by a party who disagrees with the Medical Director’s decision. Therefore,
Walgreen’s jurisdiction argument is without merit.
Causation
Ms. Wilhelm must show that her injuries arose primarily out of and in the course
and scope of her employment. See Tenn. Code Ann. § 50-6-102(14)(A). Neither of the
physicians disputed Ms. Wilhelm’s need for knee-replacement surgery.4 Instead, they
disagreed on whether that need was primarily caused by her work injury.
A trial court generally has the discretion to choose which expert to accredit when
there is a conflict of expert opinions. Brees v. Escape Day Spa & Salon, 2015 TN Wrk.
Comp. App. Bd. LEXIS 5, at *14 (Mar. 12, 2015). In evaluating conflicting expert
testimony, a trial court may consider, among other things, “the qualifications of the experts,
the circumstances of their examination, the information available to them, and the
evaluation of the importance of that information through other experts.” Id.Although Dr. McCall is the authorized treating physician, his causation opinion is
not afforded a presumption of correctness because he was not selected from a panel of
4
Neither, apparently, did the Utilization Review physician. Instead, it appears the only reason the surgery
was not approved was the proposed use of the MAKO robot.
physicians. See Gilbert v. United Parcel Serv., Inc., 2019 TN Wrk. Comp. App. Bd. LEXIS
20, at *13 (June 7, 2019). However, after reviewing the doctors’ testimony and considering
the other factors set out in Brees, the Court finds Dr. McCall’s opinion to be more
persuasive. He not only treated Ms. Wilhelm, but also he performed the surgery and
personally observed the interior condition of her knee.
Case law generally supports this conclusion. “It seems reasonable that the physicians
having greater contact with the Plaintiff would have the advantage and opportunity to provide
a more in-depth opinion, if not a more accurate one.” Orman v. Williams Sonoma, Inc., 803
S.W.2d 672, 677 (Tenn. 1991); see also Smith v. TrustPoint Hosp., LLC, 2021 TN Wrk.
Comp. App. Bd. LEXIS 1, at *21 (Jan. 6, 2021) (trial court did not err in accepting the
authorized treating physician’s opinion over that of another expert, where the authorized
physician had the benefit of seeing the employee’s condition during surgery, which
confirmed his pre-operative diagnoses, and where the authorized physician “followed
Employee as a patient and saw her lack of progress with conservative care firsthand.”)
Dr. Gavigan, on the other hand, performed a record review. He never examined Ms.
Wilhelm or spoke with her about her injury or the onset and progression of her symptoms.
He was unfamiliar with the procedure used in her surgery, and no evidence showed that he
personally looked at any of her x-ray or MRI films.
These differences matter because the central dispute between the doctors is the
extent to which Ms. Wilhelm’s pre-existing arthritis caused the need for her knee
replacement. Dr. Gavigan focused on the chondromalacia observed by Dr. Petit, which
was not caused by the work injury. Then, a few months after the meniscus surgery, the x-
rays showed a loss of joint space, which Dr. Gavigan agreed was a new finding. Less than
a month later, the joint space was completely collapsed. He characterized this as “advanced
arthritis” justifying a knee replacement, but he concluded that the primary cause of the need
for knee replacement was the ongoing arthritis. The basis for this opinion was, “I believe
the torn meniscus would not result in the joint space narrowing that quickly.”
Dr. McCall, on the other hand, provided a detailed explanation of how meniscal root
tears commonly cause this rapid progression of arthritis and said he had observed similar
degeneration in as little as three months after an attempted root repair. While he
acknowledged Ms. Wilhelm might have needed a knee replacement later in life, she would
not have needed it at this time, were it not for the work injury.
Walgreen contended that Dr. McCall’s execution of the Physician Certification
Form, after Ms. Wilhelm had already returned to work, suggested that his testimony was
too biased to be reliable. The Court disagrees. The doctor could not recall why he had
signed the form and believed he did so by mistake. Without more, this is insufficient to
disregard Dr. McCall’s thorough explanation of the mechanism of injury or to question the
veracity of his testimony. Further, his conclusion about the rapid decline of Ms. Wilhelm’s
knee condition is supported by her unrefuted testimony that until this injury, she was able
to do her work without any problems or knee pain.5
Finally, Walgreen objected to what it perceives as a return to the liberal construction
of the statute in Utilization Review disputes, based ostensibly on the treating physician’s
presumption of correctness.6 As applied to this case, this argument improperly conflates
the issues of causation and medical necessity, and it is unpersuasive on both counts.
Walgreen’s argument is inapplicable to the issue of causation in this case, because, as noted
above, Dr. McCall’s opinion is not entitled to that presumption. Instead, his opinion was
simply more persuasive than Dr. Gavigan’s, and Utilization Review does not address
causation questions.
On the other hand, Dr. McCall is presumed to be correct on the question of medical
necessity and reasonableness. See Tennessee Code Annotated section 50-6-204(a)(3)(H).
However, this was not an issue for the hearing, as all the doctors agreed knee replacement
was necessary and reasonable. To the extent the necessity of the MAKO procedure was
called into question, that issue expired at the end of the six-month period in the rules.
Further, as Walgreen offered no evidence regarding the Utilization Review physician’s
interpretation of the treatment guidelines, the proof would have been insufficient to
overcome the presumption.
For these reasons, the Court finds that Ms. Wilhelm met her burden of proving by a
preponderance of the evidence that her need for knee replacement was primarily caused by
the August 19, 2019 work injury.
Permanent Disability
Because Ms. Wilhelm’s knee replacement is compensable, she is entitled to receive
5
While causation of an injury must be shown by expert medical testimony, medical proof “must be
considered in conjunction with the lay testimony of the employee as to how the injury occurred and the
employee's subsequent condition.” Thomas v. Aetna Life & Cas. Co., 2015 TN Wrk Comp App Bd LEXIS
15, at *9 (May 27, 2015).
6
Walgreen asked, “What’s the employer supposed to do? Is it supposed to pay just because the ATP
recommended it?” It maintained it chose not to pay for this procedure “because it was told it didn’t have
to. . . We have rules, and we should follow those rules.” The Appeals Board addressed this question in
Walls v. United Technologies Corp., 2021 TN Wrk Comp App Bd LEXIS 27, at *22, 23 (Aug. 6, 2021).
“Nothing in the statute relieves an employer of its burden of proof or the consequences of its decision to
deny medical treatment merely because it sought utilization review of the prescribed treatment, then relied
on the reviewing physician’s ‘decertification’ recommendation. The utilization review provider does not
deny an employee's request for medical treatment, nor does the Bureau's Medical Director. Ultimately, the
decision to approve or deny medical treatment recommended by an authorized physician rests with the
employer and, perhaps, its insurer. An employer can choose to authorize treatment even if its utilization
review physician recommends ‘decertification.’ See Tenn. Comp. R. & Regs. 0800-02-06-.06(6)(a) . . . [I]t
is the employer that must accept the consequences of its decision to deny such treatment if that decision
turns out to be ‘erroneous, incorrect, or otherwise inconsistent with the law or facts.’”
permanent partial disability benefits for that condition. See Tenn. Code Ann. § 50-6-
207(3)(A).
Dr. McCall testified that the rating for Ms. Wilhelm’s knee replacement under the
AMA Guides, 6th edition is ten percent to the body. This equals forty-five weeks of
permanent partial disability benefits at the stipulated compensation rate of $921.83, or
$40,560.52. The parties agreed that Walgreen was entitled to a set-off of $1,475.87, based
on an overpayment of employer-funded short-term disability paid instead of temporary
disability benefits. Thus, her permanent partial disability award is $39,084.65.
Medical Benefits
The Workers’ Compensation Law requires an employer to provide reasonable,
necessary treatment at no cost to the injured worker. Tenn. Code Ann. § 50-6-204. The parties
stipulated that, if the Court found the knee replacement compensable, Walgreen would be
responsible for satisfying any outstanding claims for payment, subrogation, or
reimbursement of the related medical expenses. Therefore, Walgreen shall provide future
medical benefits with Dr. McCall and shall pay Ms. Wilhelm’s medical providers and
health insurer under the fee schedule. It shall also reimburse Ms. Wilhelm for her out-of-
pocket payments.
IT IS, THEREFORE, ORDERED as follows:
1. Walgreen shall provide reasonable and necessary future medical benefits with
Dr. McCall for Ms. Wilhelm’s left-knee work injury.
2. Walgreen shall reimburse the health insurer under the fee schedule for payments
to Dr. McCall, the surgery center, physical therapy, and any other providers for
her knee-replacement surgery.
3. Walgreen shall reimburse Ms. Wilhelm for her out-of-pocket payments from her
knee-replacement surgery.
4. Walgreen shall pay Ms. Wilhelm permanent partial disability benefits of
$39,084.65.
5. Ms. Wilhem’s attorney is entitled to a twenty-percent fee from this award under
Tennessee Code Annotated section 50-6-226(a)(1), or $8,112.10. Ms.
Wilhelm’s attorney may file a motion for discretionary costs and an affidavit
under Rule 54 of the Tennessee Rules of Civil Procedure within seven days of
the date of this Order.
6. The Court taxes the $150.00 filing fee to Walgreen, to be paid to the Court Clerk
under Tennessee Compilation Rules and Regulations 0800-02-21-.06 (February,
2022) within five business days of this order becoming final, and for which
execution might issue if necessary.
7. Walgreen shall file a Statistical Data Form (SD-2) with the Court Clerk within
five business days of the date this order becomes final.
8. Unless appealed, this order shall become final thirty days after entry.
ENTERED March 16, 2022.
_________________________
Judge Dale Tipps
Court of Workers’ Compensation Claims
APPENDIX
Exhibits:
1. Transcript of Dr. William Gavigan’s deposition
2. Transcript of Dr. Scott McCall’s deposition
3. Medical Director’s letter of July 27, 2020
4. June 10, 2020 Utilization Review report of Dr. Steven Arsht
5. Ms. Wilhelm’s responses to Walgreen’s Requests for Admissions
Technical record:
1. Petition for Benefit Determination
2. Dispute Certification Notice
3. Request for Expedited Hearing
4. Scheduling Order
5. Employer’s Pre-Hearing Brief
6. Employee’s Pre-Hearing Brief
7. Joint Pre-Compensation Hearing Statement
8. Employer’s Witness and Exhibit List
9. Employee’s Witness and Exhibit List
CERTIFICATE OF SERVICE
I certify that a copy of this Compensation Order was sent as indicated on March 16,
2022.
Name Certified Email Service Sent To
Mail
Jill T. Draughon, X jdraughon@hughesandcoleman.com
Employee’s Attorney
John R. Lewis, X john@johnlewisattorney.com
Employer’s Attorney
_____________________________________
Penny Shrum, Clerk
Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov
Compensation Hearing Order Right to Appeal:
If you disagree with this Compensation Hearing Order, you may appeal to the Workers’
Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers’
Compensation Appeals Board, you must:
1. Complete the enclosed form entitled: “Notice of Appeal,” and file the form with the
Clerk of the Court of Workers’ Compensation Claims within thirty calendar days of the
date the compensation hearing order was filed. When filing the Notice of Appeal, you
must serve a copy upon the opposing party (or attorney, if represented).
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
calendar days after filing of the Notice of Appeal. Payments can be made in-person at
any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
alternative, you may file an Affidavit of Indigency (form available on the Bureau’s
website or any Bureau office) seeking a waiver of the filing fee. You must file the fully-
completed Affidavit of Indigency within ten calendar days of filing the Notice of
Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will
result in dismissal of your appeal.
3. You bear the responsibility of ensuring a complete record on appeal. You may request
from the court clerk the audio recording of the hearing for a $25.00 fee. A licensed court
reporter must prepare a transcript and file it with the court clerk within fifteen calendar
days of the filing the Notice of Appeal. Alternatively, you may file a statement of the
evidence prepared jointly by both parties within fifteen calendar days of the filing of the
Notice of Appeal. The statement of the evidence must convey a complete and accurate
account of the hearing. The Workers’ Compensation Judge must approve the statement
of the evidence before the record is submitted to the Appeals Board. If the Appeals
Board is called upon to review testimony or other proof concerning factual matters, the
absence of a transcript or statement of the evidence can be a significant obstacle to
meaningful appellate review.
4. After the Workers’ Compensation Judge approves the record and the court clerk transmits
it to the Appeals Board, a docketing notice will be sent to the parties. The appealing
party has fifteen calendar days after the date of that notice to submit a brief to the
Appeals Board. See the Practices and Procedures of the Workers’ Compensation
Appeals Board.
To appeal your case directly to the Tennessee Supreme Court, the Compensation Hearing
Order must be final and you must comply with the Tennessee Rules of Appellate
Procedure. If neither party timely files an appeal with the Appeals Board, the trial court’s
Order will become final by operation of law thirty calendar days after entry. See Tenn.
Code Ann. § 50-6-239(c)(7).
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
NOTICE OF APPEAL
Tennessee Bureau of Workers’ Compensation
www.tn.gov/workforce/injuries-at-work/
wc.courtclerk@tn.gov | 1-800-332-2667
Docket No.: ________________________
State File No.: ______________________
Date of Injury: _____________________
___________________________________________________________________________
Employee
v.
___________________________________________________________________________
Employer
Notice is given that ____________________________________________________________________
[List name(s) of all appealing party(ies). Use separate sheet if necessary.]
appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the
Workers’ Compensation Appeals Board (check one or more applicable boxes and include the date file-
stamped on the first page of the order(s) being appealed):
□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________
□ Compensation Order filed on__________________ □ Other Order filed on_____________________
issued by Judge _________________________________________________________________________.
Statement of the Issues on Appeal
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Parties
Appellant(s) (Requesting Party): _________________________________________ ☐Employer ☐Employee
Address: ________________________________________________________ Phone: ___________________
Email: __________________________________________________________
Attorney’s Name: ______________________________________________ BPR#: _______________________
Attorney’s Email: ______________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
* Attach an additional sheet for each additional Appellant *
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Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________
Appellee(s) (Opposing Party): ___________________________________________ ☐Employer ☐Employee
Appellee’s Address: ______________________________________________ Phone: ____________________
Email: _________________________________________________________
Attorney’s Name: _____________________________________________ BPR#: ________________________
Attorney’s Email: _____________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
* Attach an additional sheet for each additional Appellee *
CERTIFICATE OF SERVICE
I, _____________________________________________________________, certify that I have forwarded a
true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described
in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this
case on this the __________ day of ___________________________________, 20 ____.
______________________________________________
[Signature of appellant or attorney for appellant]
LB-1099 rev. 01/20 Page 2 of 2 RDA 11082