                IN THE SUPREME COURT OF IOWA

                                    No. 13–0303

                                 Filed March 7, 2014


MIKE BROOKS, INC., and GREAT WEST CASUALTY CO.,

      Appellants,

vs.

JAMES DAVID HOUSE,

      Appellee.


      On review from the Iowa Court of Appeals.



      Appeal      from     the    Iowa   District   Court    for   Polk   County,

Christopher L. McDonald, Judge.



      An employee seeks further review of a court of appeals decision

reversing   a   district    court    ruling   upholding     the    Iowa   Workers’

Compensation Commissioner’s award of permanent total disability

benefits for an employee’s back injury.             DECISION OF COURT OF

APPEALS VACATED; DISTRICT COURT JUDGMENT AFFIRMED.



      Stephen W. Spencer and Joseph M. Barron of Peddicord, Wharton,

Spencer, Hook, Barron & Wegman, LLP, West Des Moines, for appellants.



      Martin Ozga of Neifert, Byrne & Ozga, P.C., West Des Moines, for

appellee.
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HECHT, Justice.

       The court of appeals concluded a workers’ compensation award of

permanent total disability benefits was not supported by sufficient

medical evidence providing a causal link between the claimant’s injury

and    his    employment.         Upon      further    review,    we    conclude      the

commissioner’s       factual    finding     on   causation       was    supported      by

substantial evidence.       We therefore vacate the decision of the court of

appeals and affirm the district court ruling affirming the commissioner’s

award of permanent total disability benefits.
       I. Background Facts and Proceedings.

       The following facts are supported by substantial evidence in the

agency record. James David House is forty-eight years old and has had a

career as a commercial truck driver. In 2002, he was involved in a motor

vehicle accident resulting in injuries to his shoulder, neck, fibula, and

cheek bone. In January 2004, while driving for C&C Distribution, House

injured his neck again while trying to push a truck tire onto a rack. He

underwent a cervical spine fusion and entered into a workers’

compensation settlement of the 2004 injury claim based upon a 26.2 %

industrial disability.

       House began working as a commercial truck driver for Mike

Brooks, Inc.,1 on July 26, 2005. On March 7, 2007, House sustained a

back injury when he slipped and fell in an icy parking lot while retrieving

cargo. The safety director for Brooks directed House to have his injury

evaluated by Lori Bailey, ARNP-FNPC. On March 14, Bailey noted House

was experiencing pain at a “9 on a 0-10 pain scale,” loss of sleep “due to

the back discomfort,” and an inability “to stand up straight secondary to

       1For ease of reference, we shall refer in this opinion to Mike Brooks, Inc. and its
workers’ compensation carrier, Great West Casualty Company, as “Brooks.”
                                     3

the pain.”   Bailey initially diagnosed House’s symptoms as “[l]ow back

spasms,” prescribed medications and physical therapy, ordered an MRI,

and released House to return to work with certain restrictions. The MRI

report “indicat[ed] a L4, L5 disc herniation with a protrusion of the disc

material left paracentral extending to the margins of the nerve roots that

exit at L5, L6 on the left.” Based on these findings, Bailey recommended

House discontinue physical therapy and referred him to Dr. David

Hatfield, an orthopedic surgeon.

      Dr. Hatfield evaluated House on April 6, 2007. At that time, House
reported “pain in his back and down the right lower extremity” as a

result of “a slip on the ice.” Dr. Hatfield confirmed Bailey’s diagnosis of

muscle spasms and a disc protrusion at the L4–5 level, administered an

epidural injection, prescribed physical therapy, and released House to

return to work with significant restrictions.

      On May 4, House again saw Dr. Hatfield who noted House’s

buttock and leg symptoms had dramatically improved but the pain and

stiffness in his back had persisted.            A second epidural injection

scheduled for that day was postponed by Dr. Hatfield because House

reported symptomatic improvement.         Dr. Hatfield released House to

return to work without restrictions, as House was very eager to get back

to his full activities.   On August 6, Dr. Hatfield opined House had

achieved maximum medical improvement (MMI) as of May 4 and

assigned a five percent permanent physical impairment rating as a

consequence of House’s March 7 injury.

      House passed an Iowa Department of Transportation (IDOT)

physical examination and returned to work. He continued to experience
regular back pain after doing so. In early January 2008, House told his

supervisors at Brooks that his back pain had become so severe it “was
                                       4

tearing [him] up,” and that he needed pain medications.            House was

again directed to see Bailey.        While working in the course of his

employment on January 4, House pushed open a heavy door and

experienced an increase in pain and a burning sensation in the area of

his March 7, 2007 back injury, which he described as feeling like

“somebody stuck a red hot poker in [his] back.”2

      Bailey examined House again on January 16, 2008. Bailey gave

House an injection that day for pain management, prescribed other

medications, scheduled another MRI study, and referred House back to
Dr. Hatfield. The new MRI report showed “[p]rogressing left paracentral

and lateral disc protrusion at L4-5 disc space causing moderate spinal

stenosis and encroachment of the non exited L5 nerve roots, left greater

than the right from the previous exam of [March 22, 2007].”

      On January 31, 2008, Dr. Hatfield performed a L4–5 bilateral

discectomy on House.         Following the discectomy, House reported

persisting back pain and stiffness on three occasions to Dr. Hatfield in

February and March.       House was released to return to work and he

passed another IDOT physical examination on April 1. The examination

report noted House was experiencing “[i]ntermittent discomfort” and

swelling at and near the incision cite. Still taking over-the-counter and

prescription pain medications as needed, House returned to work, but he

continued to experience severe pain in his back.

      On April 23, Dr. Hatfield noted House complained of “significant

pain in his right buttock and posterior aspect of his thigh to the level of

approximately his knee,” and “at the lumbosacral junction on the right.”

Dr. Hatfield ordered another MRI, prescribed pain medication, and

      2 The record does not reveal whether the January 4, 2008 incident predated
House’s report to supervisors that his back pain had become unmanageable.
                                          5

advised House to cease working pending the results of the MRI.                      In

November 2008, Dr. Hatfield performed surgeries to fuse the L5–S1 and

L4–5 levels of House’s spine.           Concluding House attained MMI on

July 22, 2009, Dr. Hatfield released him to work with permanent

restrictions involving lifting, bending, and twisting, and limited House to

“waist to shoulder level” work only.           Dr. Hatfield opined House had

sustained     a   physical    impairment      of   twenty-three     percent    as   a

consequence of the work-related injury. House never returned to work

for Brooks.
       House filed a petition for workers’ compensation benefits. 3 The

evidence presented at the contested case hearing included the opinion of

Dr. Kuhnlein who examined House and reported:

             I would agree with Dr. Hatfield that the changes were
       related to the March 7, 2007, incident. After recovery, Mr.
       House relates that he continued to have pain at work, with
       the subsequent incident while opening the door, which
       would represent a sequela of the original injury, as he did not
       have back pain before. The March 7, 2007, injury was a
       substantial contributing factor to all of the back problems
       treated by Dr. Hatfield, up to and including the surgeries.

(Emphasis added.) After the contested hearing, a deputy commissioner

found House had sustained a permanent total disability.                 The deputy

commissioner rejected Brooks’ contention that the January 4, 2008
incident resulted in an injury distinct from the March 7, 2007 slip-and-

fall injury. He also rejected Brooks’ further contention that the March 7,

2007 slip-and-fall had not resulted in disability and that the disability

resulting from the prior neck injury was greater than any disability

       3 Around the same time, House also filed a review-reopening petition in the
proceeding against C&C Distribution. There he alleged that his cervical spine problems
had worsened since the settlement in 2006. House received no additional workers’
compensation benefits, however, as a consequence of this review-reopening proceeding.
House made no claim that his cervical spine problems were related to his work at
Brooks.
                                           6

caused by the back injury.4 On intra-agency appeal, the commissioner

affirmed the arbitration decision including the finding that House’s injury

and resulting permanent total disability were caused by the March 7,

2007 incident. Brooks sought judicial review.

       The district court found substantial evidence supported the

agency’s causation finding and affirmed the award of permanent total

disability benefits. Brooks appealed, and we transferred the case to the

court of appeals.      The court of appeals concluded the commissioner’s

finding of causation was not supported by substantial evidence in the
record. The court of appeals noted “the causal connection [found by the

commissioner between the March 7, 2007 injury and House’s disability]

was made by the experts with a lack of critical information” regarding the

January 4, 2008 incident. In particular, the court of appeals emphasized

that neither Bailey’s nor Dr. Hatfield’s notes made reference to the 2008

incident. Discounting Dr. Kuhnlein’s opinion because it was “internally

inconsistent”5 and because it relied in part on the opinion of Dr. Hatfield

who was not informed of the 2008 incident, the court of appeals further

found “the sequence of events in this case” and the totality of the




       4Brooks   requested apportionment of any disability resulting from the 2004 and
2007 injuries under Iowa Code section 85.34(7)(a) in the arbitration proceeding. As we
affirm the district court’s ruling affirming the commissioner’s award of permanent total
disability benefits, we do not consider the apportionment issue here. See Drake Univ. v.
Davis, 769 N.W.2d 176, 185 (Iowa 2009) (stating permanent total disability benefits are
not subject to apportionment under section 85.34(7)).
       5 The court of appeals perceived an inconsistency between Dr. Kuhnlein’s
statement that House “relates that he continued to have pain at work, with the
subsequent incident while opening the door,” and the doctor’s opinion that the door-
opening incident was “a sequela of the original injury, as [House] did not have back
pain before.” As we believe a reasonable fact finder could interpret the phrase “did not
have back pain before” in this context as Dr. Kuhnlein’s reference to the fact that House
did not have a problem with back pain prior to the 2007 injury, we cannot conclude the
commissioner erred as a matter of law in crediting Dr. Kuhnlein’s opinion or in rejecting
Brooks’ theory of causation.
                                    7

circumstances did not support the agency’s conclusion.        We granted

House’s application for further review.

      II. Scope of Review.

      Iowa Code chapter 17A governs our review of the commissioner’s

decision. See Iowa Code § 86.26 (2009); Watson v. Iowa Dep’t of Transp.,

829 N.W.2d 566, 568 (Iowa 2013). The district court acts in an appellate

capacity when reviewing the commissioner’s decisions to correct errors of

law. See Watson, 829 N.W.2d at 568; Ludtke v. Iowa Dep’t of Transp.,

646 N.W.2d 62, 64 (Iowa 2002). “On appeal, we apply the standards of
chapter 17A to determine whether we reach the same conclusions as the

district court. If we reach the same conclusions, we affirm; otherwise we

may reverse.” Watson, 829 N.W.2d at 568 (citation omitted).

      The legislature has by a provision of law vested the commissioner

with the discretion to make factual determinations. Finch v. Schneider

Specialized Carriers, Inc., 700 N.W.2d 328, 330–31 (Iowa 2005). Medical

causation is a question of fact vested in the commissioner’s discretion.

Cedar Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 844 (Iowa

2011).   We are bound by the commissioner’s factual determinations if

they are supported by “substantial evidence in the record before the

court when that record is viewed as a whole.” Iowa Code § 17A.19(10)(f);

accord Watson, 829 N.W.2d at 568; Finch, 700 N.W.2d at 331.

Substantial evidence is

      the quantity and quality of evidence that would be deemed
      sufficient by a neutral, detached, and reasonable person, to
      establish the fact at issue when the consequences resulting
      from the establishment of that fact are understood to be
      serious and of great importance.

Iowa Code § 17A.19(10)(f)(1).     “Evidence is not insubstantial merely
because different conclusions may be drawn from the evidence.” Pease,
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807 N.W.2d at 845. On appeal, our task “is not to determine whether

the evidence supports a different finding; rather, our task is to determine

whether substantial evidence . . . supports the findings actually made.”

Id.

      III. Discussion.

      Our analysis is shaped largely by the deference we are statutorily

obligated to afford the commissioner’s findings of fact.     Affording the

appropriate deference here, we must conclude the district court correctly

affirmed the agency’s factual finding that House sustained a work-related
injury and resulting disability on March 7, 2007.       We are bound to

uphold this factual finding on appeal, as it is supported by substantial

evidence when the record is viewed as a whole.            See Iowa Code

§ 17A.19(10)(f); Watson, 829 N.W.2d at 568.

      House presented the opinions of two medical experts, each of

whom concluded House’s back injury and all subsequent treatment and

surgeries were causally related to the slip-and-fall incident of March 7,

2007. On December 18, 2009, Dr. Hatfield, the surgeon to whom House

had been referred by the nurse practitioner for Brooks, wrote: “Based on

a review of my records I would relate [House’s] lumbar changes and

subsequent surgery to his 7 March 2007 incident as describe[d] in his

records.” As we have noted above, Dr. John D. Kuhnlein, who performed

an independent medical examination of House on June 21, 2010, opined

the door-opening incident in 2008 was a sequela of the 2007 injury.
      “[T]he determination of whether to accept or reject an expert
opinion is within the ‘peculiar province’ of the commissioner.”     Pease,
807 N.W.2d at 845 (quoting Deaver v. Armstrong Rubber Co., 170 N.W.2d
455, 464 (Iowa 1969)).     The commissioner found the expert medical
opinions of Dr. Hatfield and Dr. Kuhnlein convincing on the issue of
                                         9

medical causation. Even assuming Dr. Hatfield was unaware of the 2008
door-opening incident, the commissioner could find on this record that
Dr. Kuhnlein’s    opinion    on     causation     was   based   on   a    thorough
independent physical exam            and review of       House’s medical and
employment history including the 2008 door-opening incident.                  The
commissioner considered all of the expert medical opinions “together
with all other evidence introduced bearing on the causal connection
between the injury and the disability.”           Sherman v. Pella Corp., 576
N.W.2d 312, 321 (Iowa 1998). The evidence includes Bailey’s notes from
January 16, 2008, which confirm House had experienced persistent low
back pain “since his initial injury in March.” In preoperative history and
physical exam notes from January 29, 2008, Dr. Abeladro Cruz reported
House’s chief complaint was “[l]ow back pain since March 2007, [which
had been] worse in the past 1 month.” In addition, House testified he
experienced pain every day following the March 7, 2007 injury and the
sequence of events established by other record evidence amply supports
this testimony.       Brooks offered no other medical evidence tending to
prove the January 4, 2008 incident was a distinct injury or a cause-in-
fact   of   House’s    industrial   disability.     Accordingly,     we   conclude
substantial evidence amply supports the causation finding actually made
by the commissioner, and we are not at liberty to disturb it on the
ground the evidence could support a different determination.
       IV. Conclusion.
       For the reasons stated above, we vacate the decision of the court of
appeals and affirm the district court’s decision affirming the Iowa
Workers’ Compensation Commissioner’s award of permanent total
disability benefits for House’s back injury.
       DECISION OF COURT OF APPEALS VACATED; DISTRICT
COURT JUDGMENT AFFIRMED.
