                                                                                                  FILED
                                                                                               Jan 29, 2019
                                                                                               01:20 PM(CT)
                                                                                           TENNESSEE COURT OF
                                                                                          WORKERS' COMPENSATION
                                                                                                 CLAIMS




             TENNESSEE BUREAU OF WORKERS' COMPENSATION
                                           \
            IN THE COURT OF WORKERS' COMPENSATION CLAIMS
                           AT MURFREESBORO

Anthony Reed,                                         )   Docket No. 2017-05-0061
           Employee,                                  )
v.                                                    )   State File No. 38456-2017
Nissan N.A., Inc.                                     )
             Employer,                                )   Judge Robert Durham
v.                                                    )
Safety Nat'l Cas. Corp.,                              )
             Carrier.                                 )


                            COMPENSATION HEARING ORDER


       This Court conducted a compensation hearing on January 11, 2019. At issue are
the impairment rating for Mr. Reed' compensable bilateral carpal tunnel syndrome and
whether he suffered a work-related injury to his right cubital tunne1. 1 The Court holds
that Dr. Jeffrey Hazlewood's impairment rating is entitled to more weight than that given
by Dr. S. R. Brown. The Court further holds Mr. Reed proved that he is entitled to
treatment for his right cubital tunnel.

                                           History of Claim

       Mr. Reed has worked for Nissan for over thirty-four years. Over the decades, he
performed a variety of jobs that required him to lift and maneuver heavy car parts
hundreds of times each day as well as use air drills and other vibratory tools. For the last
several years, he has worked as lead technician responsible for correcting defects on
newly-manufactured vehicles. Mr. Reed estimated that during his tenure with Nissan, he
worked six full days per week eighty percent of the time, and there were several instances
where he worked twelve-hour shifts, seven days per week, for months at a time.

        Mr. Reed first experienced pain and numbness in his hands in 2000. He received
1
  The parties stipulated that: Mr. Reed's bilateral carpal tunnel syndrome is compensable; he is only
seeking medical benefits for his asserted right cubital tunnel injury; his compensation rate is $888.60; and
he is not owed any medical expenses or temporary disability benefits.
treatment with the physician at Nissan's in-house clinic and began wearing braces on
both arms. However, he did not receive additional treatment or miss work from this
condition until2015, when he complained of a work injury to his chest and left shoulder.
While treating for this injury, his left upper extremity complaints led to an EMG/NCS
with physiatrist Jeffrey Hazlewood, who diagnosed him with moderately severe left
carpal tunnel syndrome (CTS).

       The Nissan physician told Mr. Reed that the CTS was not work-related, so he
sought treatment through his health insurance with orthopedistS. R. Brown. Dr. Brown
performed a left carpal tunnel release, which alleviated Mr. Reed's symptoms. However,
he continued to complain of right-arm problems. Dr. Brown ordered an EMG/NCS with
neurologist Robert Clendenin, which revealed moderately severe CTS in Mr. Reed's right
arm. Dr. Brown then performed a right carpal tunnel release in April2015.

       Approximately one year later, Mr. Reed's upper extremity symptoms resurfaced.
He returned to Dr. Brown, again under his health insurance, complaining of stiffness with
numbness and tingling in both hands. Dr. Brown recommended repeat EMG/NCS
studies with Dr. Clendenin performing the test on the right and Dr. Hazlewood doing so
for the left. Dr. Clendenin noted only mild post-surgical improvement in the right carpal
tunnel, and he also diagnosed Mr. Reed with mild right cubital tunnel syndrome. Dr.
Hazlewood's testing revealed no post-surgical improvement in the left arm. Based on
these tests, Dr. Brown diagnosed Mr. Reed with recurrent bilateral CTS and cubital
tunnel syndrome. She recommended Mr. Reed undergo bilateral revision open carpal
tunnel releases. She also felt the CTS and cubital tunnel syndrome were primarily caused
by Mr. Reed's employment with Nissan.

      Nissan agreed to provide Mr. Reed with a panel. He chose Dr. Hazlewood, who
saw him on July 17,2017. Dr. Hazlewood's report was inexplicably titled "Independent
Medical Evaluation with Option to Treat." After explaining the independent medical
evaluation (IME) process to Mr. Reed, Dr. Hazlewood conducted an examination and
reviewed his history. He found Mr. Reed credible with no evidence of symptom
magnification. He concluded that Mr. Reed suffered from bilateral carpal tunnel
syndrome that had not improved with surgery. However, he disagreed with Dr. Brown's
diagnosis of cubital tunnel syndrome. .

       Nissan then authorized Dr. Brown to perform bilateral open revision carpal tunnel
releases, but it denied treatment for cubital tunnel syndrome. 2 Following recovery, Dr.
Brown gave an impairment of six percent to each upper extremity, which she converted
to seven percent to the whole body. Nissan sent Mr. Reed back to Dr. Hazlewood for his
impairment rating, and he assessed two percent to the right arm and four percent to the

2
The agreement was memorialized in a Notice of Mediated Agreement filed with the Bureau on August
16,2017.

                                               2
left, which converted to three-percent whole body.

        Dr. Brown testified by deposition. She stated that Mr. Reed reported substantial
improvement after surgery. She said she based her impairment on her physical
examination as well as EMG/NCSs that showed "conduction blocks for motor and
sensory components of the nerve." She assigned six-percent impairment to each
extremjty using Table 15-23 of the AMA Guides to the Evaluation of Pennanent
Impairment, 6th ed. (' Guides"). She believed this section gave her the discretion to
assign four, five or six percent, so she chose six percent given the severity of Mr. Reed's
symptoms and the EMG findings. When she converted and combined those impairments,
it resulted in eight-percent impairment to the body, as opposed to the seven percent she
gave in her report.

       Dr. Brown also testified that Table 15-21 of the Guides gave an impairment of six
percent to each extremity. She said that she did not use a "QuickDash" functional
assessment to determine impairment modifiers within the grade used because Table 15-
23 did not require it. 3 On cross-examination, she admitted she did not use a two-point
discrimination test to assess sensory loss. Finally, she conceded that she never received
any formal training in assessing impairment.

       As to causation, Dr. Brown gave her opinion that Mr. Reed suffers from bilateral
carpal tunnel syndrome and right cubital tunnel syndrome that primarily arose out of and
in the course and scope of his employment. She acknowledged that she could not recall
Mr. Reed's actual job duties, although the case manager provided her with a written
description at some point. She also agreed that she saw Mr. Reed on several occasions
without noting elbow complaints.

       Dr. Hazlewood also gave deposition testimony. Regarding impairment, he stated
he received extensive training in using the Guides and also taught other physicians how
to use them on several occasions. After Mr. Reed selected him from a panel, Dr.
Hazlewood characterized his status as Mr. Reed's authorized treating physician because
he rendered a diagnosis and causation opinion. However, he admitted he did not provide
any actual treatment.

       At his impairment assessment, Mr. Reed exhibited positive Tinel's sign bilaterally,
and his motor exam was "completely normal" with no motor weakness or atrophy. Mr.
Reed had normal pinprick and two-point discrimination testing in all five fingers of both
hands.



3
 Table 15-21 states that Table 15-23 should be used for carpal tunnel syndrome. Pages 448-449 of the
Guides, under the section titled "Rating Process," state that the QuickDash assessment should be used to
"further modify the grade and to choose the appropriate numerical impairment rating."

                                                   3
       In evaluating the right arm, Dr. Hazlewood had to use Dr. Clendenin's pre-surgery
EMG/NCS because that was the only one available. He noted that Dr. Clendenin did not
document the arm temperature at the time of testing, which is required by the Guides to
ensure accuracy. He also felt that Dr. Clendenin did not perform a "very specific
technique" necessary to determine if there was axon loss or motor/sensory blocks, which
the Guides states is necessary if using Table 15-23 for impairment.

       Nevertheless, Dr. Hazlewood believed that Mr. Reed was a "straight-up guy [who]
had a valid problem," so he decided to use Table 15-23 to calculate right-arm
impairment. The table uses diagnostic tests, history, and physical findings to determine
certain grades of impairment. First, he found that Mr. Reed should be in Grade 1 for
diagnostic tests, since Dr. Clendenin's test did not record a nerve block or axon loss.
Second, since Mr. Reed's constant pain and numbness were not corroborated by
documented axon loss, he placed him in Grade 2 for history. As for physical findings, he
placed Mr. Reed in Grade 1, since his exam did not reveal evidence of sensory loss or
muscle atrophy. When averaged, the total grade modifier placed him in Grade 1, or an
impairment of one, two, or three percent to the right arm.

       To determine the exact impairment, Dr. Hazlewood had Mr. Reed complete a
QuickDash questionnaire, which asks about the difficulty the patient has in performing
certain activities. He testified that, under Tennessee law, he should not consider pain as a
factor in determining impairment. This, he believed, "discredited" the QuickDash test
from consideration. Regardless, he asked Mr. Reed to take the survey using only
numbness and weakness as factors. He scored 25, which placed Mr. Reed in the middle
category. Thus, Dr. Hazlewood concluded that his right carpal tunnel syndrome
"deserves a two percent upper extremity rating, not anything more, not anything less."

       As for the left arm, Dr. Hazlewood testified that his diagnostic tests, done in
accordance with the Guides, revealed a sensory block. This placed Mr. Reed in Grade 2
for diagnostic tests. Given the block and Mr. Reed's complaints, Dr. Hazlewood put him
in Grade 3 for history. However, he did not find any sensory loss or muscle atrophy;
therefore, he assessed him at Grade 1 for physical findings. When averaged, these results
placed Mr. Reed in Grade Modifier 2, which gives an impairment of four, five, or six
percent to the upper extremity. Mr. Reed's QuickDash score of 25 required the
impairment to be adjusted down by one percent, giving him an impairment of four
percent. 4 Dr. Hazlewood converted and combined the impairments for a three-percent
whole body impairment.

      Regarding causation, Dr. Hazlewood reviewed Mr. Reed's job description. He
noted the job duties did not appear to require prolonged bent-elbow positioning. He

4
  Dr. Hazlewood gave him the test again but asked him to use pain as a factor. Mr. Reed's score on this
test would have increased his impairment for each extremity by a percentage point.

                                                  4
testified he did not feel Mr. Reed had true ulnar neuropathy given the minimal findings
on Dr. Clendenin's EMG study, and even if he did, it was not work-related. However, he
agreed with Dr. Brown that Mr. Reed's bilateral carpal tunnel syndrome met the
causation standard for compensability.

        Mr. Reed testified that, although the symptoms have improved since his surgeries,
he still experiences constant pain and tingling in both hands. He has decreased his work
hours from an average of sixty to seventy hours per week to forty-five. He also stated
that he often has help from his co-workers when a job requires forceful grasping. Daily
tasks involving grasping, pulling, or carrying cause significant problems. He has to shift
hands frequently when driving because they go numb from holding the steering wheel.
Turning a doorknob causes severe pain in either hand. To sleep, he still has to wear
braces on both hands.

                        Findings of Fact and Conclusions of Law

       Mr. Reed has the burden of proving by a preponderance of the evidence all
essential elements of his workers' compensation claim. Scott v. Integrity Staffing
Solutions, 2015 TN Wrk. Comp. App. Bd. LEXIS 24, at *6 (Aug. 18, 2015). Here, the
only issues are the extent of Mr. Reed's vocational disability for his work-related bilateral
carpal tunnel syndrome and whether Nissan is required to pay for treatment of Mr.
Reed's asserted right cubital tunnel syndrome.

       The Court must first address which doctor is authorized to treat Mr. Reed. The
question is important, since the authorized doctor's opinions on causation and impairment
are presumed correct unless rebutted by a preponderance of the evidence. Tenn. Code
Ann.§ 50-6-102(12)(A)(ii) (causation); 50-6-207(k)(7) (impairment).

       Nissan rejected Mr. Reed's claim until Dr. Brown, who had already performed
carpal tunnel releases on both wrists, gave a positive causation opinion. Nissan then
provided Mr. Reed with a panel from which he chose Dr. Hazlewood, who performed an
"independent medical evaluation with option to treat." Although Dr. Hazlewood insisted
that he was acting as a treating physician, he did not provide any actual treatment or
recommend a treatment plan.

        Nissan then authorized Dr. Brown to perform surgery. No evidence suggested that
Dr. Brown ever referred Mr. Reed back to Dr. Hazlewood. Tennessee Code Annotated
section 50-6-204(a)(2)(E) provides that when the treating physician chosen from the
initial panel refers an employee to a surgeon who subsequently provides treatment, that
surgeon becomes the "treating physician" until treatment concludes and the surgeon
refers the employee back to the initial panel physician.

      Here, Nissan argued that Dr. Brown is not the "treating physician" because she

                                             5
was never chosen from a panel and Dr. Hazlewood never expressly referred Mr. Reed to
her. This argument is without merit. Nissan clearly authorized Dr. Brown to perform the
carpal tunnel revision surgeries. It cannot now claim that she was not the treating
physician simply because it agreed to bypass the statutory steps. In addition, the Court is
unconvinced that Dr. Hazlewood qualified as an initial treating physician, given the title
of his report and the fact that he did not provide or even recommend treatment. Thus, the
Court holds that Dr. Brown was the treating physician for Mr. Reed's bilateral carpal
tunnel syndrome and her opinion as to impairment is entitled to a presumption of
correctness.

       However, that does not end the analysis. Nissan can still prevail if the evidence
rebuts Dr. Brown's opinion by a preponderance of the evidence. The Court holds the
evidence does just that.

        Dr. Brown's opinion as to impairment is lacking in several respects. She admitted
she has no training in providing impairments under the Guides. Her inaccuracy in
combining impairments and her statement that Table 15-21 also gave a six-percent
impairment, when the table clearly states it is not to be used in assessing carpal tunnel
syndrome, illustrate this point. She also incorrectly stated that the electrodiagnostic
summaries indicated Mr. Reed suffered from both motor and sensory blocks. Dr.
Hazlewood specifically stated that his EMG/NCS did not show a motor block and that
Dr. Clendenin's report did not record "specific testing" needed to show conduction
blocks or axon loss. Dr. Brown admitted that she did not perform two-point
discrimination testing. She also did not make any attempt to determine functional
disability, because in her words, Table 15-23 did not require it. She also mistakenly
stated the table gave her discretion to award four, five or six percent. Given these factors,
the Court cannot give weight to Dr. Brown's impairment ratings.

        On the other hand, Dr. Hazlewood has extensive training in the Guides and has
even taught its application to other physicians. He is also an expert in electrodiagnostic
testing, which must be used to rate impairment for CTS under the Guides. He gave a
detailed account of his assessment for both hands and provided his rationale for each
step. The Court holds that Dr. Hazlewood's procedure and testimony justify giving his
impairment more weight in this case. 5

      Therefore, the Court holds that Mr. Reed's impairment is two percent for the right
arm and four percent for the left. When converted and combined, his overall impairment

5
  The Court recognizes that the impairment might have been different if Dr. Clendenin's pre-surgery
EMG/NCS had been more detailed. Further, this holding should not be considered a complete
endorsement of Dr. Hazlewood's method, particularly his decision to use his own modified QuickDash
evaluation to downgrade Mr. Reed's left arm impairment. While the Court has reservations as to this
modification, the lack of credible medical evidence to the contrary compels the Court to accept Dr.
Hazlewood's impairment as is.

                                                6
is three percent to the body as a whole.

        As for the cubital tunnel syndrome, Dr. Brown, who has treated Mr. Reed for
several years, unequivocally gave her opinion that he suffers from cubital tunnel
syndrome in his right arm and that it arose primarily out of and in the course and scope of
his employment with Nissan. Her opinion was corroborated by Dr. Clendenin, a
respected neurologist. So, even if Dr. Hazlewood is considered the treating physician for
this condition, the Court holds that the evidence preponderates against his opinion that
Mr. Reed does not suffer from work-related right cubital tunnel syndrome. Dr. Brown,
who has already provided treatment and recommended a course of action, shall be the
treating physician for this condition.

 IT IS, THEREFORE, ORDERED as follows:

  1.   Mr. Reed's vocational disability is three percent to the body as a whole, which
       equates to $11,998 at his compensation rate of $888. Nissan shall pay $11,998 in
       a lump sum from which his counsel is awarded twenty percent, or $2,397 .60, as
       attorney's fees.

 2.    Dr. S. R. Brown shall be Mr. Reed's treating physician for his work-related
       bilateral carpal tunnel syndrome and his right cubital tunnel syndrome. Nissan
       shall pay for the reasonable and necessary medical treatment for these injuries.

 4.    Nissan shall pay court costs of $150 to the Court Clerk within five business days
       of this order becoming final. Nissan shall also reimburse Mr. Reed for reasonable
       litigation expenses, including but not limited to Dr. Brown's witness fee and court
       reporter fees.

 5.    Nissan shall prepare and submit a Statistical Data Form within ten business days
       of the date this order becomes final.

 6.    Absent an appeal, this order shall become final thirty days after issuance.

ENTERED JANUARY 29, 2019.




                                             7
                                    APPENDIX
Exhibits:
1.     Dr. Brown's deposition
2.     Dr. Hazlewood's deposition
3.     Letter from Dr. Hazlewood to Dr. Brown
4.    Notice of Mediated Agreement-January 13, 2017
5.    Notice of Mediated Agreement-April17, 2017
6.     Choice of Physician Form
7.    Letter from Mr. Reed's counsel to Mediator Tonya Murphy
8.    Notice of Mediated Agreement-August 16, 2017
9.    Employee/Manager Medical Statement
10.   Referral Intake Form for Dr. Hazlewood
11.   Petition for Benefit Determination with attachments
12.   Certified records from Dr. Brown
13.   Medical records made exhibits to Dr. Hazlewood's deposition

Technical Record:
1.    Petition for Benefit Determination
2.    Dispute Certification Notice
3.    Scheduling Order
4.    Mr. Reed's Pre-Compensation Hearing Statement
5.    Nissan' s Compensation Hearing Brief
6.    Joint Pre-Compensation Hearing Statement
7.    Post-Mediation Dispute Certification Notice


                           CERTIFICATE OF SERVICE

       I hereby certify that a true and correct copy of the Compensation Hearing Order
Granting Benefits was sent to the following recipients by the following methods of
service on January 29, 2019.

Name                   Certified   Via    Via Service sent to:
                        Mail       Fax   Email
R. Steven Waldron                         X    arlenesmith@wfptnlaw.com
Thomas Tucker                             X    ttucker@veazeytucker .com




                                                         erk of Court



                                          8
                                 II
                                  I                                                       'I



                          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: "Compensation Hearing 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 ofthe 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 lndigency 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.
II                                                                                                                      I.
 '                                                                                                                       I




                                    Tennessee Bureau of Workers' Compensation
                                           220 French Landing Drive, 1-B
                                             Nashville, TN 37243-1002
                                                      800-332-2667

                                               AFFIDAVIT OF INDIGENCY


     I,                                                , having been duly sworn according to law, make oath that
     because of my poverty, I am unable to bear the costs of this appeal and request that the filing fee to appeal be
     waived. The following facts support my poverty.

     1. Full Name:_ _ _ _ __ _ _ _ _ __                       2. Address: - - - - - - - -- - - --

     3. Telephone Number: - - - - - - - - -                   4. Date of Birth: - - - - -- - - -- -

     5. Names and Ages of All Dependents:

             - - - - - - - - - - - - - - -- - Relationship: - - - - - - -- - - -- -

             - - - - - - - - - - - - - -- --                  Relationship: - - - - - -- - - -- - -

             - - - - - - - - - - -- - -- - - Relationship: - - - -- - -- - - - - -

             - - - - - - - - - - - - - - -- -                 Relationship: - - - - - - -- - - -- -

     6. I am employed by: - - - - - - - - - - -- - - -- - - - - - -- - - -- - -

             My employer's address is: - - - - -- - - - -- - - - - - -- - -- - - - -

             My employer's phone number is: - - - -- - - - -- - - - - - -- - - -- - -

     7. My present monthly household income, after federal income and social security taxes are deducted, is:

     $ _ _ _ _ _ __

     8. I receive or expect to receive money from the following sources:

             AFDC            $            per month           beginning
             SSI             $            per month           beginning
             Retirement      $            per month           beginning
             Disability      $            per month           beginning
             Unemployment $               per month           beginning
             Worker's Camp.$              per month           beginning
             Other           $            per month           beginning



     LB-1108 (REV 11/15)                                                                               RDA 11082
9. My expenses are:     ! ~                                                      li
                                                                                  I
                          '

        Rent/House Payment $              per month     Med icai/Dental $ _ _ ___ per month

        Groceries       $           per month           Telephone       $ _ __ _ _ per month
        Electricity     $           per month           School Supplies $ _ _ _ _ _ per month
        Water           $           per month           Clothing        $ _ _ _ _ _ per month
        Gas             $           per month           Child Care      $ _ _ _ _ _ per month
        Transportation $            per month           Child Support   $ _ _ _ _ _ per month
        Car             $            per month
        Other           $           per month (describe:


10. Assets:

        Automobile              $ _ _ _ __
                                                        (FMV) - - - - - - - - - -
        Checking/Savings Acct. $ _ _ _ __
        House                   $ _ _ __
                                                        (FMV) - - - - - - - - - -
        Other                   $ _ _ _ __              Describe:_ _ _ _ __ _ __ __


11. My debts are:

        Amount Owed                     To Whom




I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
and that I am financially unable to pay the costs of this appeal.




APPELLANT



Sworn and subscribed before me, a notary public, this

____ dayof _____________________ , 20_ __




NOTARY PUBLIC

My Commission Expires:_ _ _ _ _ _ __




LB-1108 (REV 11/15)                                                                          RDA 11082
