                   IN THE SUPREME COURT OF IOWA
                                 No. 06–1748

                             Filed March 19, 2010


AMY ANN SCHUTJER,

      Appellant,

vs.

ALGONA MANOR CARE CENTER
and IOWA LONG TERM CARE
RISK MANAGEMENT ASSOCIATION,

      Appellees.



      On review from the Iowa Court of Appeals.



      Appeal from the Iowa District Court for Kossuth County, Joseph J.

Straub, Judge.



      Employer seeks further review of court of appeals’ decision in appeal of

workers’ compensation case.        DECISION OF COURT OF APPEALS

VACATED IN PART; DISTRICT COURT JUDGMENT AFFIRMED, AND

CASE REMANDED.



      Mark S. Soldat of Soldat & Parrish-Sams, P.L.C., West Des Moines, for

appellant.



      Michael L. Mock of Bradshaw, Fowler, Proctor & Fairgrave, P.C.,

Des Moines, for appellees.
                                       2

TERNUS, Chief Justice.

      This workers’ compensation case comes to us on further review from

the court of appeals.   The appellee, Algona Manor Care Center, does not

dispute that the appellant, Amy Schutjer, sustained an injury to her lower

back on December 2, 2002, that arose out of and in the course of her

employment with Algona Manor.         In fact, Algona Manor paid Schutjer

temporary benefits. The parties do, however, disagree with respect to the

following matters: (1) the correct rate for benefits, (2) Schutjer’s entitlement

to additional temporary total and temporary partial disability benefits, (3)

Schutjer’s entitlement to permanent partial disability benefits, and (4) the

propriety of penalty benefits.    The workers’ compensation commissioner

sided with Algona Manor on these issues, agreeing with Algona Manor’s

calculation of the rate and awarding no additional benefits.

      On Schutjer’s appeal to the district court, the court determined the

employer had incorrectly calculated the rate, and the commissioner had

improperly refused to award temporary benefits for certain days between

December 2, 2002, and January 4, 2003.         The district court affirmed the

commissioner’s decision with respect to a denial of temporary benefits after

January 4, 2003, finding substantial evidence to support the commissioner’s

determination that Schutjer voluntarily quit her employment on January 5.

The district court also affirmed the commissioner’s refusal to award

permanent partial disability benefits. Finally, the court concluded that, in

view of the court’s reversal as to the correct rate, the commissioner should

reconsider whether penalty benefits should be imposed.

      Both parties appealed, and the case was transferred to the court of

appeals.   That court affirmed the district court with respect to the proper

rate and the need for reconsideration of penalty benefits. As for temporary

benefits, the court of appeals agreed with the district court that Schutjer was
                                             3

entitled to temporary benefits for certain days between December 2, 2002,

and January 4, 2003. The court of appeals disagreed with the district court

on two issues. The court of appeals concluded that the commissioner had

not properly analyzed the question of Schutjer’s entitlement to temporary

benefits after she left employment on January 5, and that the commissioner

had failed to provide adequate detail in his decision to support his

conclusion that Schutjer had no permanent disability. Therefore, the court

of appeals reversed the denial of temporary benefits after January 5, 2003,

and the denial of permanent partial disability benefits.

       Algona Manor sought further review.             We granted further review to

consider whether the commissioner properly determined Schutjer was not

entitled to temporary benefits after January 4, 2003, and whether the

commissioner adequately detailed his reasons for finding Schutjer had not

sustained a permanent disability. See Anderson v. State, 692 N.W.2d 360,

363 (Iowa 2005) (“On further review, we can review any or all of the issues

raised on appeal or limit our review to just those issues brought to our

attention by the application for further review.”). 1            We find no basis for

reversal with respect to either matter. Therefore, we vacate that part of the

court of appeals’ decision reversing the district court on these two issues.
We affirm the district court’s decision and remand the case to the district

court for further proceedings.

       I. Factual and Procedural Background.

       We limit our recitation of the evidence and history of this case to those

facts and rulings that are pertinent to the two issues we have chosen to

address on further review.



       1On   all other issues raised on appeal, the court of appeals’ decision stands as the
final ruling. See Everly v. Knoxville Cmty. Sch. Dist., 774 N.W.2d 488, 492 (Iowa 2009).
                                      4

      A. Injury and Medical Treatment.          At the time of her injury on

December 2, 2002, Amy Schutjer worked as a certified nursing assistant

(CNA) at Algona Manor Care Center. On that date, she and another CNA

were transferring a resident from the resident’s bed to a wheelchair. During

this maneuver, Schutjer experienced a sharp pain in her left hip area that

radiated into her back and down her left leg.

      Algona Manor immediately sent Schutjer to the Kossuth Regional

Health Center where Schutjer saw a physician’s assistant.             Schutjer

described what had happened and denied any history of prior back

problems,   even   though   her   medical   and   employment    records   from

approximately 1991 onward indicate numerous complaints of back pain,

including a back injury in 1991 as a result of being thrown from a horse. X-

rays of the lumbrosacral spine and left hip taken at the health center were

essentially normal.    Due to her continued complaints of severe pain,

Schutjer was administered a pain medication injection and given a

prescription for pain medication.      She was also taken off work until

December 9, 2002.

      On December 9, 2002, Schutjer returned to the health center for a

scheduled appointment with Dr. Burt Bottjen.           Schutjer reported to

Dr. Bottjen that the pain medication had not helped much. After observing

and examining the patient, Dr. Bottjen concluded her complaints were

exaggerated and inconsistent with the reported injury.      He increased her

pain medication and advised her to work with her workers’ compensation

carrier to find another physician, as he would not be able to help her.

      The employer authorized care with Dr. Kevin Culbert. Dr. Culbert first

saw Schutjer on December 12, 2002.          In relaying her medical history,

Schutjer again denied any history of back problems. She also provided a

somewhat different version of the incident that precipitated her current pain,
                                      5

stating that during the transfer the resident slipped, jerking Schutjer’s back

forward in a flexed position. Dr. Culbert diagnosed Schutjer with acute low

back pain with left sciatica. He prescribed medication, continued physical

therapy, and ordered modified work duties to include no lifting over ten

pounds, no bending or twisting, no stooping or crouching, and no pushing or

pulling.

      The employer constructed and provided Schutjer’s supervisors with a

list of light-duty activities that would be appropriate for Schutjer to perform

within her restrictions. Schutjer returned to work on December 17, 2002.

      On December 27, 2002, Schutjer underwent an MRI that showed

bulging at L4–5, but no significant encroachment on the spinal canal. Due

to Schutjer’s continuing pain, Dr. Culbert maintained duty restrictions,

continued her pain medication, and ordered a consult with anesthesiology

for pain management.

      On January 2, 2003, Schutjer received a lumbar epidural steroid

injection. That same day, she notified Dr. Culbert that she was not getting

much help at work to stay within restrictions and had to do some bending,

twisting, and pulling. Dr. Culbert advised Schutjer to speak to the charge

nurse or head of human resources about this.

      On January 5, 2003, Schutjer reported to work, but a few hours after

the shift started, Schutjer and the charge nurse got into a dispute when the

nurse requested that Schutjer clean commode buckets, bedpans, and

urinals. Schutjer advised the nurse that she could not bend down to clean

commodes.    According to the charge nurse, when she instructed Schutjer

that Schutjer could still clean the urinals, Schutjer became angry, swung

her arms around, stating “I’m leaving, I quit,” and stormed out the door.

      The following day, the nursing supervisor informed the workers’

compensation claims adjuster that Schutjer had terminated her employment
                                       6

with Algona Manor.      The claims adjuster informed the supervisor that

Schutjer had called the carrier and left a message about the incident in

which she claimed she was being asked to do tasks she could not do. The

supervisor denied this was the case.

       That same day, Schutjer called the supervisor to ask, “What’s going

on?”   Schutjer denied she had quit the night before, claiming the charge

nurse had asked her to leave. The supervisor countered, however, that it

was her understanding the charge nurse had asked Schutjer to leave only

after Schutjer had twice refused to follow the charge nurse’s request to clean

urinals.    Upon reconfirmation of the facts with the charge nurse, the

supervisor advised Schutjer that Algona Manor was accepting her “I quit” as

her termination. Schutjer did not return to Algona Manor to work after this

incident.

       Schutjer continued to see Dr. Culbert for her low back pain. Having

been advised by Schutjer that she had obtained no relief with the epidural

injection, Dr. Culbert referred her to Dr. Palit, an orthopedic surgeon.

       On January 22, 2003, Dr. Palit saw Schutjer for the first time. After

examining her and reviewing the prior MRI, Dr. Palit’s diagnosis was “mild

lumbar degenerative disc disease” for which he ordered physical therapy and

allowed light-duty work with a twenty-pound lifting restriction and no

bending, twisting, kneeling, or crawling. However, like Dr. Bottjen, Dr. Palit

found “[t]he patient’s pain complaints and manifestation . . . out of

proportion to her physical and radiographic findings.” He was also surprised

by her report that, the night before, she had experienced an acute onset of

total paralysis from the waist down that lasted about an hour. His surprise

focused on the fact that Schutjer did not seek medical care because “[s]he

knew [she] was going to see [me] the next morning.”            Dr. Palit found
                                      7

Schutjer’s attitude about this alleged incident to be “very cavalier” “for this

apparently devastating experience of total paralysis.”

      On February 28, 2003, Schutjer returned to see Dr. Palit for ongoing

low back pain with bilateral lower extremity pain. Schutjer reported that she

had not gone to physical therapy at this point. She had, however, obtained

employment in the Hy-Vee floral department and, according to Dr. Palit,

reported working up to twelve hours per day. (At the subsequent workers’

compensation hearing, Schutjer claimed she only worked a maximum of six

hours per shift at Hy-Vee.) After examination, Dr. Palit determined Schutjer

had reached maximum medical improvement as of February 28, 2003. He

released her to regular duty and directed her to continue taking her anti-

inflammatory medication.

      Between February 19, 2003, and March 26, 2003, Schutjer also

sought care for her back pain with Jensen Chiropractic. On her last three

visits for manipulation, March 17, 19, and 26, 2003, Schutjer reported no

complaints.   At the subsequent workers’ compensation hearing, however,

Schutjer testified that only her continued treatment with Dr. Jensen made

work at the floral department bearable.      On March 27, 2003, the claims

adjuster for the workers’ compensation carrier advised Schutjer that her

chiropractic treatment was not authorized and that she either needed to

return to Dr. Palit or needed to request alternative medical treatment.

Schutjer did not request alternative care.

      On April 3, 2003, Schutjer sought treatment from Dr. Arthur

Doenecke for her continuing and long-standing problems with anxiety and

depression.   Dr. Doenecke ordered Prozac for depression and Ambien for

sleep and made a psychiatric referral.       He also referred Schutjer to a

podiatrist for two ingrown toenails she had asked him to examine. There

was no mention in the medical notes that Schutjer reported any continuing
                                     8

back, hip, or leg problems. Two later doctor visits on April 15 and May 8,

2003, make no reference to any complaints of continuing back, hip, or leg

problems.     Schutjer also continued her employment with Hy-Vee until

April 28, 2003, when she quit because she needed to be involved in seeking

a loan for a new home.

      At the subsequent workers’ compensation hearing, Schutjer testified

that she did not seek medical attention for her back and continued to work

even though the pain still existed because her husband would not allow her

to seek medical attention through his insurance.          The testimony of

Schutjer’s husband corroborated this assertion.

      Schutjer’s next medical treatment for back pain occurred on June 4,

2003, when she saw Dr. David Taylor. At that time, she complained of some

numbness in her left leg with pain sometimes radiating down to her left foot.

Schutjer reported to Dr. Taylor that this problem started with the

December 2, 2002 incident at Algona Manor. She also reported to Dr. Taylor

that her prior MRI showed a bulging disc. Due to her pain and symptomatic

examination, Dr. Taylor determined it was necessary to rule out a herniated

disc and ordered another MRI and a consultation with a neurosurgeon,

Dr. Beck.   He did not place Schutjer on any pain medication due to her

concerns about chronic use of narcotics.       Several days later, however,

Schutjer called complaining of continued pain with no relief and was

restarted on Darvocet N, which she had at home.

      Schutjer’s neurosurgery consultation with Dr. Beck occurred on

June 16, 2003.    Dr. Beck found the patient to be quite histrionic upon

physical examination. He read the December MRI as showing a little disc

degeneration and minimal bulge at L4–5 and told Schutjer this. Because she

claimed her pain was much worse, however, he agreed to proceed with a

second MRI.
                                      9

        The second MRI, performed on June 18, 2003, was essentially the

same as the first. Nonetheless, because Schutjer continued to complain of

severe bilateral leg and back pain, Dr. Beck concluded a discogram was

warranted to determine if L4–5 was a symptomatic disc.           That test,

performed on June 26, 2003, revealed a tear in the annulus posteriorly at

L4–5 and some degeneration at L5–S1. Based upon these positive findings,

Dr. Beck recommended Schutjer undergo spinal fusion at the level of L4–5.

Schutjer underwent the procedure on July 10, 2003.

        Although her initial post-op period was uneventful, Schutjer was

subsequently hospitalized for three days for back and right leg pain in late

August 2003. The pain started two weeks prior after she heard a pop in her

back.

        In a follow-up visit on September 27, 2003, Dr. Beck found that

Schutjer continued to have back pain that severely restricted her activity.

He recommended she continue on significant restrictions of minimum

sitting, standing, and a twenty-pound weight limit.      X-rays showed an

excellent fusion, however, and on examination the patient was neurologically

intact. In December, upon inquiry, Dr. Beck opined Schutjer had suffered a

twelve percent body-as-a-whole impairment.

        Dr. Palit, upon the same inquiry, opined that Schutjer reached

maximum medical improvement on February 28, 2003, and that she did not

require any further medical care other than taking nonsteroidal anti-

inflammatory medication.     He also opined that the July surgery was not

medically necessary based on his evaluation earlier in 2003 and that the

surgery was not causally related to her work injury.
        As a result of the two conflicting medical expert opinions, Schutjer

requested an independent medical examination. On August 23, 2004, this

examination was completed by Dr. John Kuhnlein, an occupational and
                                      10

environmental specialist.   Dr. Kuhnlein also concluded Schutjer exhibited

histrionic behavior. In response to the question of whether, to a reasonable

degree of osteopathic certainty, it was probable that cumulative work

activities at Algona Manor, the December 2, 2002 incident, or both,

constituted a substantial, but not necessarily exclusive, factor in causing

injury to Schutjer’s back and leg, Dr. Kuhnlein opined:

      If one discounts her histrionic behaviors and focuses on the
      objective complaints, it appears that the sensory complaints
      from December of 2002 were mirrored in June and July of 2003
      indicating the same source. However, she had a period of
      several months where she was apparently pain free. She relates
      that she was taking pain medications, but in review of the only
      notes I have available from the medical clinic, she was placed on
      Prozac for depression, and I do not see any specific indication
      she was on pain medications until June of 2003.
      My sense is that physiologically the two are related, but based
      on the currently available medical record, and given Worker’s
      Compensation scenario, I cannot objectively make the
      relationship between the December 2002 injury and the June
      2003 pain, given the several month interval where no back pain
      is mentioned.

      B. Workers’ Compensation Proceeding and Judicial Review.                  On

September 4, 2003, Schutjer filed a workers’ compensation claim against

Algona     Manor    and   Cannon    Cochran      Management        Services,   Inc.,

administrator for Algona Manor’s workers’ compensation carrier, Iowa Long

Term Care Risk Management Association.          (Our subsequent references to

Algona Manor include its carrier, where indicated by the context.) A hearing

on   the   matter   was   held   before    a   deputy   workers’    compensation

commissioner, Helenjean M. Walleser (hereinafter “deputy”).           Pertinent to

this appeal, the parties disputed, among other issues, (1) whether the

December 2, 2002 injury was a cause of permanent disability and, if so, to

what extent, and (2) whether Schutjer was entitled to healing period

compensation or temporary partial benefits after she left employment on

January 5, 2003.
                                       11

        On March 10, 2005, the deputy filed an arbitration decision, finding

(1) the December 2, 2002 work injury was not a cause of permanent

disability, and (2) Schutjer was not entitled to any healing period or

temporary partial benefits beyond those for which Algona Manor had already

paid.    The deputy’s credibility findings were critical to her rulings.   She

specifically found that Schutjer lacked credibility. Supporting this finding

was the evidence admitted at the hearing.       Admitted into evidence at the

hearing were the medical records showing prior complaints of back pain that

Schutjer had denied having when she first sought treatment for her

December 2, 2002 injury; the testimony of Schutjer admitting that she had

made those prior complaints; the testimony of Schutjer’s husband that he

did not believe that Schutjer suffered from back pain after the workers’

compensation payments stopped, although he had later changed his mind;

the testimony of Schutjer admitting that she testified at her deposition that,

after leaving work with Algona Manor, she had not filed an unemployment

claim that had been denied, although she admitted at the hearing that she

had done so; and the testimony of Schutjer that she had committed the

felony of theft by check. In addition, as discussed above, many of the expert

medical opinions concluded that Schutjer was histrionic in her description of

pain, more than one physician finding those complaints to be exaggerated.

        Schutjer filed an application for rehearing asserting several errors in

the deputy’s findings of fact and conclusions of law.      Of relevance to the

issues we consider, Schutjer contended the deputy erred when the deputy

held “[t]he greater weight of the credible evidence would establish that

claimant voluntarily quit her employment on January 5, 2003.”         Instead,

Schutjer asserted, the greater weight of the evidence established a

withdrawal of an offer of suitable work or a failure to prove an intentional

refusal to work. After her application for rehearing was rejected, Schutjer
                                           12

appealed to the workers’ compensation commissioner, who delegated

authority to issue the final agency decision to a different deputy

commissioner, Larry P. Walshire (hereinafter “commissioner”), who adopted

the deputy’s proposed decision as the final agency decision. 2                      The

commissioner specifically noted that he was relying on the credibility

findings made by the deputy.

       Schutjer filed a petition for judicial review, alleging several errors,

including the commissioner’s failure to award temporary benefits after

January 4, 2003, and failure to award medical expenses and permanent

partial disability benefits after February 28, 2003.

       The district court concluded there was substantial evidence to support

the commissioner’s finding that Schutjer did in fact terminate—quit—her

employment with Algona Manor on January 5, 2003. As a result, the court

held the commissioner properly decided Schutjer was not entitled to

compensation for either healing period or temporary disability benefits after

that date. The district court also concluded there was substantial evidence

to support the commissioner’s finding that Schutjer sustained no permanent

disability as a result of the December 2, 2002 incident at Algona Manor.

Therefore, the court affirmed the denial of healing period benefits and

medical expenses for the time period of July through September 2003, as

well as the denial of permanent partial disability benefits.

       C. Arguments on Appeal.            Schutjer appealed, and Algona Manor

cross-appealed.      Only the matters raised by Schutjer on appeal are

implicated in the issues we address on further review.                 Those matters

include (1) Schutjer’s contention the district court erred in affirming the


       2Because  the commissioner adopted the deputy’s proposed decision, we will treat
both the deputy’s proposed decision and the commissioner’s final decision as one decision
and reference them in the remainder of this opinion as the “commissioner’s decision.”
                                        13

commissioner’s failure to award healing period or temporary disability

benefits after January 4, 2003, on the basis that she had voluntarily quit;

and   (2)   her   contention   the   district    court   erred   in   affirming   the

commissioner’s failure to award temporary disability and medical benefits

associated with her July 10, 2003 surgery and refusal to award permanent

partial disability compensation.

      D. Court of Appeals’ Decision.            We transferred this appeal to the

court of appeals. The court of appeals disagreed with the commissioner and

the district court regarding the effect of Schutjer’s voluntary quit.             The

appellate court concluded that Schutjer’s voluntary quit was irrelevant to the

issue of whether she was entitled to temporary benefits.               It held that,

pursuant to Iowa Code section 85.33(3) (2003), a two-part analysis was

necessary: (1) Was Schutjer offered suitable work within her restrictions?

and (2) If so, did she refuse it? This issue, the court concluded, required

remand to the agency for a determination as to whether, on January 5,

2003, suitable work within Schutjer’s restrictions was offered to Schutjer

and whether she refused such work.

      The court of appeals also disagreed with the district court’s affirmance

of the commissioner’s denial of benefits after February 28, 2003. The court

of appeals found the commissioner based his causation ruling solely on its

determination that Schutjer lacked credibility.            The court of appeals

concluded the agency had a duty to state the evidence relied upon and that

the commissioner’s decision must be sufficiently detailed to show the path

taken through the conflicting expert evidence. Because the court of appeals

thought the commissioner’s decision did not meet these requirements, the

court of appeals remanded the case, directing the agency to “show the path”

taken through the conflicting medical evidence and to discuss the relevant

benefits and expenses.
                                       14

      Algona Manor filed an application for further review of all of the

rulings of the court of appeals that were adverse to it.        Schutjer filed a

resistance to that application. As noted above, we granted further review to

consider two issues: (1) whether the commissioner properly ruled Schutjer

was not entitled to temporary benefits after she left employment on

January 5, 2003; and (2) whether the commissioner adequately explained

his   decision   that   Schutjer’s   medical   expenses   and   disability   after

February 28, 2003, were not causally connected to her December 2, 2002

injury.

      II. Scope of Review.

      Our review in a workers’ compensation action is governed by Iowa

Code chapter 17A.         See Iowa Code § 86.26 (2009).           Because the

commissioner’s factual determinations are “ ‘ “clearly vested by a provision of

law in the discretion of the agency,” ’ . . . we defer to the commissioner’s

factual determinations if they are based on ‘substantial evidence in the

record before the court when that record is viewed as a whole.’ ” Larson Mfg.

Co. v. Thorson, 763 N.W.2d 842, 850 (Iowa 2009) (quoting Mycogen Seeds v.

Sands, 686 N.W.2d 457, 465 (Iowa 2004) and Iowa Code § 17A.19(10)(f)).

Our assessment of the evidence focuses not on whether the evidence would

support a different finding than the finding made by the commissioner, but

whether the evidence supports the findings actually made.         Meyer v. IBP,

Inc., 710 N.W.2d 213, 218 (Iowa 2006).          “Because the commissioner is

charged with weighing the evidence, we liberally and broadly construe the

findings to uphold his decision.” Finch v. Schneider Specialized Carriers, Inc.,

700 N.W.2d 328, 331 (Iowa 2005). In addition, we give due regard to the

commissioner’s discretion to accept or reject testimony based on his

assessment of witness credibility.     See Terwilliger v. Snap-On Tools Corp.,

529 N.W.2d 267, 273 (Iowa 1995).
                                       15

        In contrast, the commissioner’s interpretation of the law is entitled to

no deference because “ ‘[t]he interpretation of the workers’ compensation

statutes and related case law has not been clearly vested by a provision of

law in the discretion of the agency.’ ” Lakeside Casino v. Blue, 743 N.W.2d

169, 173 (Iowa 2007) (quoting Finch, 700 N.W.2d at 330). We will reverse

the commissioner’s application of the law to the facts “only if the

commissioner’s application [is] ‘irrational, illogical or wholly unjustifiable.’ ”

Larson Mfg. Co., 763 N.W.2d at 850 (quoting Iowa Code § 17A.19(10)(l)).

        III. Temporary Benefits After Voluntary Quit.

        Relying on Iowa Code section 85.33(3), the commissioner ruled

Schutjer was barred from receiving benefits as of January 5, 2003, the date

that Algona Manor claims she voluntarily quit her employment. In pertinent

part, this statute provides:

        If an employee is temporarily, partially disabled and the
        employer for whom the employee was working at the time of
        injury offers to the employee suitable work consistent with the
        employee’s disability the employee shall accept the suitable
        work, and be compensated with temporary partial benefits. If
        the employee refuses to accept the suitable work with the same
        employer, the employee shall not be compensated with
        temporary partial, temporary total, or healing period benefits
        during the period of the refusal.

Iowa Code § 85.33(3).

        In this case, the commissioner made the following factual finding:

“The employer was accommodating claimant’s modified duty restrictions

during [the time after the December 2, 2002 incident.]”         In addition, the

commissioner stated the evidence established that Schutjer voluntarily quit

her employment on January 5, 2003. There is no other discussion in the

findings of fact or conclusions of law regarding the incident on January 5,

2003.
                                      16

      In reviewing the commissioner’s decision, the district court held “ ‘the

greater weight of the objective credible evidence’ indicated [Schutjer] resigned

her CNA position with Algona Care on January 5, 2003.” The district court

then went on to discuss the facts found in the record that supported the

commissioner’s finding on this issue.      It noted the factual discrepancies

between the parties with respect to what occurred on January 5. Schutjer

asserted she was asked to perform tasks not within her restrictions and

denied the allegation by the charge nurse at Algona Manor that she––

Schutjer––stormed out of the facility after announcing she had quit.         At

another point in her testimony, however, Schutjer stated: “That isn’t why I

quit,” an assertion that seems to confirm the nurse’s statement that Schutjer

quit. In contrast to Schutjer’s testimony, Algona Manor witnesses testified

Schutjer was excused from performing tasks not within her restrictions—

such as cleaning bedpans and commode buckets—and that she was only

required to clean urinals, a task within her restrictions.

      The district court correctly noted that, when there are two competing

accounts of a single event, the commissioner has the responsibility to weigh

the evidence and consider the credibility of the witnesses. See Terwilliger,

529 N.W.2d at 273. The court concluded substantial evidence supported the

finding made by the commissioner.

      The court of appeals, however, stated the issue was not whether

Schutjer voluntarily quit, but whether Schutjer was offered suitable work

within her restrictions and whether she refused it. Only if she was offered

such work and refused it would she be precluded from receiving temporary

partial, temporary total, or healing period benefits. Concluding the agency

failed to clearly address this issue, the court of appeals remanded the case

so the commissioner could make this determination.
                                       17

        We agree the correct test is (1) whether the employee was offered

suitable work, (2) which the employee refused.        If so, benefits cannot be

awarded, as provided in section 85.33(3). We conclude, however, that the

commissioner found Schutjer was offered suitable work that she refused,

and for that reason, Schutjer was not entitled to benefits as specified under

section 85.33(3). Although the commissioner’s decision is nearly devoid of

any discussion of the issue of modified duty and adherence to work

restrictions, he expressly found that the employer was accommodating

Schutjer’s modified duty restrictions during this time. Substantial evidence

supported this conclusion.        The commissioner’s finding that Schutjer

voluntarily quit satisfied the second requirement of section 85.33(3)––refusal

of suitable work.

        Schutjer argues, nonetheless, that any refusal of suitable work ended

on January 6, 2003, when she talked to the supervisor and denied that she

had quit, asserting the charge nurse had fired her. This factual dispute––

whether Schutjer quit or was fired––was resolved against her.        Therefore,

Algona Manor was justified in accepting Schutjer’s voluntary quit on

January 5, 2003, as a rejection of suitable work on that date and any future

date.

        We conclude the findings required by section 85.33(3) were made by

the commissioner, and these findings enjoy substantial support in the

record.    Therefore, we vacate the court of appeals’ contrary decision and

affirm the decision of the district court on this issue.

        IV. Benefits After Maximum Medical Improvement.

        As noted earlier, the court of appeals reversed the district court

decision affirming the commissioner’s determination that Schutjer was not

entitled to benefits after February 28, 2003, the date Dr. Palit concluded she

had reached maximum medical improvement.             To be entitled to benefits
                                      18

following this date, Schutjer had to satisfy her burden of proving that her

medical treatment subsequent to February 28, as well as any temporary or

permanent disability, was causally related to the December 2, 2002 injury.

      Schutjer argues the commissioner’s finding that her medical problems

after February 28, 2003, were not causally related to her December 2002

injury is not supported by substantial evidence.           She contends the

commissioner failed to explain the basis for his rejection of the evidence

supporting a causal connection, particularly the testimony of Dr. Beck. The

court of appeals concluded the district court erred in holding that the

commissioner found “the opinions of Dr. Palit and Dr. Kuhnlein, along with

the testimony of [Schutjer], to support the finding that [Schutjer’s]

continuing back problems were not caused by the December 2, 2002

incident at Algona Manor.” The court of appeals believed the agency based

its causation ruling solely on its determination that Schutjer lacked

credibility and that the agency failed to explain the weight given to the varied

medical opinions or explain how it resolved the conflicts in the medical

evidence.

      1. Applicable legal principles.      “A claimant must prove by a

preponderance of the evidence that the injury is a proximate cause of the

claimed disability.” Grundmeyer v. Weyerhaeuser Co., 649 N.W.2d 744, 752

(Iowa 2002).    Ordinarily, expert testimony is necessary to establish the

causal connection between the injury and the disability for which benefits

are claimed. Id. With regard to expert testimony,

      “[t]he commissioner must consider [such] testimony together
      with all other evidence introduced bearing on the causal
      connection between the injury and the disability.         The
      commissioner, as the fact finder, determines the weight to be
      given to any expert testimony. Such weight depends on the
      accuracy of the facts relied upon by the expert and other
      surrounding circumstances. The commissioner may accept or
      reject the expert opinion in whole or in part.”
                                       19

Id. (quoting Sherman v. Pella Corp., 576 N.W.2d 312, 321 (Iowa 1998)

(citations omitted)); accord Sanchez v. Blue Bird Midwest, 554 N.W.2d 283,

285 (Iowa Ct. App. 1996) (“Expert opinion testimony, even if uncontroverted,

may be accepted or rejected in whole or in part by the trier of fact.”).

      With respect to the commissioner’s written decision, Iowa Code section

17A.16(1) provides: “The [agency] decision shall include an explanation of

why the relevant evidence in the record supports each material finding of

fact. . . . Each conclusion of law shall be supported by cited authority or by

a reasoned opinion.” This duty on the part of the agency is intended to allow

a reviewing court “to ascertain effectively whether or not the presiding officer

actually did seriously consider the evidence contrary to a finding, and

exactly why that officer deemed the contrary evidence insufficient to

overcome the evidence in the record supporting that finding.”          Arthur E.

Bonfield, Amendments to Iowa Administrative Procedure Act, Report on

Selected Provisions to Iowa State Bar Association and Iowa State Government

42 rptr. cmt. (1998) [hereinafter “Bonfield”]; accord Catalfo v. Firestone Tire &

Rubber Co., 213 N.W.2d 506, 510 (Iowa 1973) (“[The commissioner’s]

decision must be sufficiently detailed to show the path he has taken through

conflicting evidence.    When he disregards uncontroverted expert medical

evidence he must say why he has done so.”); see also Tussing v. George A.

Hormel & Co., 417 N.W.2d 457, 458 (Iowa 1988) (finding commissioner’s

failure to state any reasons for rejecting overwhelming evidence, including

medical evidence, that work-related injury occurred on date in question

required reversal).     The requirement that the commissioner explain his

decision is not intended to be onerous:

      [T]he commissioner’s decision must be “sufficiently detailed to
      show the path he has taken through conflicting evidence,” [but]
      the law does not require the commissioner to discuss each and
      every fact in the record and explain why or why not he has
                                      20
      rejected it. Such a requirement would be unnecessary and
      burdensome.

Terwilliger, 529 N.W.2d at 274 (quoting Catalfo, 213 N.W.2d at 510); accord

Bonfield at 42 rptr. cmt. (stating the “requirement of a brief explanation will

not be burdensome”); see also Bridgestone/Firestone v. Accordino, 561

N.W.2d 60, 62 (Iowa 1997) (stating commissioner’s duty to furnish a

reasoned opinion is satisfied if “ ‘it is possible to work backward . . . and to

deduce what must have been [the agency’s] legal conclusions and [its]

findings of fact’ ” (quoting Norland v. Iowa Dep’t of Job Serv., 412 N.W.2d
904, 909 (Iowa 1987))).

      2. Analysis. The commissioner’s opinion does not express the step-

by-step reasoning process that led him to the conclusion that Schutjer failed

to show the December 2002 injury caused continued disability after

February 28, 2003.    Nevertheless, we conclude on this specific issue—the

connection between the December 2, 2002 injury and the subsequent

treatments after February 28, 2003, and resulting impairment—it is possible

to determine from the commissioner’s opinion what evidence he considered

and why he credited some of this evidence over other, conflicting evidence.

      As noted by the court of appeals, the agency did summarize the

medical opinions contained in the evidence.       The commissioner observed

that Dr. Palit stated Schutjer had reached maximum medical improvement

on February 28, 2003, and Dr. Palit found no permanent impairment. The

commissioner noted that Dr. Palit further opined that, based upon his

evaluation of Schutjer in January and February 2003, Schutjer’s surgery

was not causally related to her work injury and was not medically necessary.

On the other hand, the commissioner mentioned that Dr. Beck, who initially

saw Schutjer in June 2003 and eventually performed a laminectomy on her,

opined Schutjer’s December 2, 2002 injury was a substantial factor in
                                    21

causing her back pain and that under the guidelines she had a twelve

percent whole body impairment as a result of that injury.       Finally, the

commissioner discussed the opinion of the independent medical expert,

Dr. Kuhnlein. Dr. Kuhnlein, as noted previously, opined that he could not

objectively relate Schutjer’s December 2, 2002 injury to her June 2003 back

pain as Schutjer did not have a “straight record” of symptoms from her

December injury to her July surgery. The commissioner also took note of

Dr. Kuhnlein’s observation that, while Schutjer maintained she had

remained on nonsteroidal anti-inflammatory medication after her release

from Dr. Palit, the medical records did not support this.    In addition to

reviewing these medical opinions, the commissioner summarized the various

medical providers from whom Schutjer sought care during the period

between February 28, 2003, and June of 2003, specifically finding that she

did not mention any back or leg symptoms to her primary care physician or

her psychiatrist when she saw them on five separate occasions in April and

May 2003.

      At the end of his review of the medical evidence, the commissioner

stated the following conclusion:

            Claimant does not carry her burden of demonstrating that
      her December 2, 2002 work injury was a substantial factor in
      precipitating her June 2003 complaints, her July 2003 surgery,
      and her continuing low back and bilateral leg symptoms. The
      record clearly demonstrates that claimant has never been averse
      to seeking medical care. It also clearly demonstrates that
      claimant tends to complain profusely to her care providers about
      any medical conditions for which she is seeking care. Given
      those circumstances, claimant’s statements, both to medical
      providers from June 4, 2003 onward and at hearing, that she
      had continuing low back and leg symptoms from December 2,
      2002 lack credibility.

(Emphasis added.) It is apparent from the commissioner’s discussion that

he believed Schutjer would have complained of back and leg pain between
                                       22

February 2003 and June 2003 if she had continued to experience such pain

during that time. The commissioner had previously noted, however, that the

record did not indicate such complaints had been made. Accordingly, the

commissioner concluded Schutjer’s assertions of continuing symptoms

between February and June lacked credibility. This conclusion confirmed

Dr. Kuhnlein’s opinion that, in the absence of a “straight record” of

symptoms from the December 2002 injury to the July 2003 surgery, it could

not be said that the December 2002 injury was causally linked to the later

surgery and permanent impairment.

      Thus, when the commissioner’s conclusion that Schutjer’s testimony

of continuing symptoms was not credible is considered in the context of the

commissioner’s review of the medical evidence, it is evident that the

commissioner chose to rely on the opinions of Dr. Palit and Dr. Kuhnlein

because those opinions were more consistent with the factual findings made

by the commissioner with respect to the symptoms Schutjer experienced

between February and June.          Thus, it is possible to identify from the

commissioner’s causation discussion the evidentiary basis of his conclusion

and why he gave preference to the opinion testimony of Dr. Palit and

Dr. Kuhnlein.

      We   conclude,   therefore,   that    the   commissioner’s   decision   was

sufficiently detailed to permit us to ascertain that he seriously considered

the evidence for and against his finding with respect to causation, as well as

why he concluded the evidence against causation was more credible.             In

addition, the commissioner’s decision on causation is supported by

substantial evidence in the form of the expert opinions of Dr. Palit and

Dr. Kuhnlein. Therefore, we vacate the decision of the court of appeals and

affirm the decision of the district court affirming the commissioner’s ruling
                                     23

that Schutjer was not entitled to benefits for the medical expenses and

disability she sustained after February 28, 2003.

      V. Summary and Disposition.

      We conclude the commissioner found Schutjer was offered suitable

work, which she refused, and these findings are supported by substantial

evidence.   Therefore, the commissioner did not err in refusing to award

Schujter temporary benefits after she left employment. We also conclude the

commissioner adequately explained the basis for his decision that the

medical expenses and disability sustained by Schutjer after she reached

maximum medical improvement on February 28, 2003, were not causally

connected to her December 2, 2002 injury.       Because the commissioner’s

finding on causation is supported by substantial evidence, we affirm the

commissioner’s decision that Schutjer is not entitled to medical benefits or

disability benefits for the period subsequent to February 28, 2003.

      DECISION OF COURT OF APPEALS VACATED IN PART; DISTRICT

COURT JUDGMENT AFFIRMED, AND CASE REMANDED.

      All justices concur except Baker, J., who takes no part.
